Information Collection

Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)

IC 228398 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attach 6 Telephone Screener.docx	Other-Telephone script
National Survey of Hospital-based Victim Services Attach 1 Questionnaire 090817.docx	Form
Respondent Data Sheet Attach 8 Respondent Data Sheet.docx	Form
Attach 2 Invitational Letter.docx Invitation letter	IC Document
Attach 3 Newspaper Ad&Flyer.docx Advertisement	IC Document
Attach 4 Support Letter.docx Letter of Support	IC Document
Attach 5 Interviewer Intro Ltr.docx Introductory Letter	IC Document
Attach 7 Informed Consent.docx Consent	IC Document
Attach 9 Thank You Ltr.docx Thank you Letter	IC Document
Attach 10 Special Consent.docx Consent for Recording	IC Document
10-day letter Hospital based 092917.docx OMB request letter	IC Document

IC Title:

Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)

Agency IC Tracking Number:

0920-0222-17BCS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Telephone script			Attach 6 Telephone Screener.docx	Yes	Yes	Fillable Fileable
Form	none	National Survey of Hospital-based Victim Services	Attach 1 Questionnaire 090817.docx	Yes	Yes	Fillable Fileable
Form	none	Respondent Data Sheet	Attach 8 Respondent Data Sheet.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probablity Samples of the US Population

FR Citation: 49 FR 37693

Number of Respondents: 92

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Invitation letter	Attach 2 Invitational Letter.docx	09/20/2017
Advertisement	Attach 3 Newspaper Ad&Flyer.docx	09/20/2017
Letter of Support	Attach 4 Support Letter.docx	09/20/2017
Introductory Letter	Attach 5 Interviewer Intro Ltr.docx	09/20/2017
Consent	Attach 7 Informed Consent.docx	09/20/2017
Thank you Letter	Attach 9 Thank You Ltr.docx	09/20/2017
Consent for Recording	Attach 10 Special Consent.docx	09/20/2017
OMB request letter	10-day letter Hospital based 092917.docx	09/29/2017

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