Traumatic Brain Injury Surveillance System

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Adolescent Survey	Form	New	Repair queued
Adolescent Screener	Form	New	Repair queued
Adult-Proxy Survey	Form	New	Repair queued
Adult-Proxy Screener	Form	New	Repair queued
Eligibility Screener	Form	New	Repair queued
H-1 Contact Attempt Protocols.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
G-1 Table Shells.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-10 Intro-Assent for Adol-Spanish.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-9 Consent Adult for Adol-Spanish.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-8 Consent Adult Proxy-Spanish.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-7 Consent Adult Not Proxy-Spanish.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-6 Introduction Script-Spanish.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-5 Intro-Assent for Adol-English.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-4 Consent Adult for Adol-English.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-3 Consent Adult Proxy-English.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-2 Consent Adult Not Proxy-English.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
F-1 Introduction Script-English.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
D-1 ICF IRB Approval Letter.pdf	Supplementary Document	Uploaded 2016-08-15	Repair queued
C-1 Consultants.docx	Supplementary Document	Uploaded 2016-08-15	Repair queued
B-1 60 Dy FRN.pdf	Supplementary Document	Uploaded 2016-08-15	Repair queued
A-2 TBI Reauthorization Act of 2014.pdf	Supplementary Document	Uploaded 2016-08-15	Repair queued
A-1 Public Health Service Act.doc	Supplementary Document	Uploaded 2016-08-15	Repair queued
SSB_TBI Surveillance_30D_16_Updated 08082016.docx	Supporting Statement B	Uploaded 2016-08-15	Repair queued
SSA_TBI Surveillance_30D_16_Updated 08082016.docx	Supporting Statement A	Uploaded 2016-08-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223032	Adolescent Survey	Form	New
223031	Adolescent Screener	Form	New
223030	Adult-Proxy Survey	Form	New
223028	Adult-Proxy Screener	Form	New
223027	Eligibility Screener	Form	New

ICR Details

OMB Control No:	ICR Reference No: 201608-0920-010
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AOP
Title: Traumatic Brain Injury Surveillance System
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted	Conclusion Date: 07/13/2017
	Date Received in OIRA: 08/25/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC proposes to pilot test survey and methodology that will form the basis of a traumatic brain injury (TBI) surveillance system, and then implement the full surveillance system. The system will determine how many children and adults experience a TBI each year in the US, collect information about the circumstances of the injury, and identify groups most at risk for TBI.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
   US Code: 42 USC 393B Name of Law: CDC Programs for Prevention and Surveillance of TBI
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 38182	06/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 57587	08/23/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Adult-Proxy Screener	none, none	Adult-Proxy Screener - English ,   Adult-Proxy Screener - Spanish
Eligibility Screener	none, none	Eligiiblity Screener - English ,   Eligibility Screener - Spanish
Adult-Proxy Survey	none, none	Adult-Proxy Survey - English ,   Adult- Proxy Survey - Spanish
Adolescent Screener	none, none	Adolescent Screener - English ,   Adolescent Screener - Spanish
Adolescent Survey	none, none	Adolescent Survey - English ,   Adolescent Survey - Spanish

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $1,811,177

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/25/2016

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