Spanish Cognitive Study to Examine Traumatic Brain Injury Questions

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Document Name Document Type
Spanish Cognitive Study to Examine Traumatic Brain Injury Questions Form
Spanish Questions - TBI Spanish TBI Attach 1 Qnne.docx Form
Spanish Telephone Screener Spanish TBI Attach 3 phone screener.docx Form and Instruction
Spanish Data Collection Sheet Spanish TBI Attach 5 Resp Data Collect.docx Form
Spanish TBI 10-day letter 081116.docx Letter to Dr. Schwab IC Document
Spanish TBI Attach 2a&b ad&flyer.docx Advertisement/Flyer IC Document
Spanish TBI Attach 4 Informed Consent.docx Consent IC Document
Spanish TBI Attach 6 ThankYou letter.docx Thank you Letter IC Document
Spanish TBI Attach 7 Special Consent.docx Video Consent IC Document

Information Collection (IC) Details

IC Title:	Spanish Cognitive Study to Examine Traumatic Brain Injury Questions	Agency IC Tracking Number:	16AZR

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Spanish Questions - TBI	Spanish TBI Attach 1 Qnne.docx	Yes	No	Fillable Fileable
Form and Instruction	none	Spanish Telephone Screener	Spanish TBI Attach 3 phone screener.docx	Yes	No	Fillable Fileable
Form	none	Spanish Data Collection Sheet	Spanish TBI Attach 5 Resp Data Collect.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 58	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	58	58
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter to Dr. Schwab	Spanish TBI 10-day letter 081116.docx	08/15/2016
Advertisement/Flyer	Spanish TBI Attach 2a&b ad&flyer.docx	08/15/2016
Consent	Spanish TBI Attach 4 Informed Consent.docx	08/15/2016
Thank you Letter	Spanish TBI Attach 6 ThankYou letter.docx	08/15/2016
Video Consent	Spanish TBI Attach 7 Special Consent.docx	08/15/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.