Information Collection

Hospital-Based Victim Services Frame Development Project

IC 235734 under ICR 201703-0920-003 · OMB 0920-1030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1030 Hospital-Based Victim Services Frame Development Project	Form and Instruction
0920-1030 Telephone Script Attachment B - NSHVS Telephone Script 040319.docx	Form and Instruction
NSHVS Project - GenIC Statement A 040319 ICRO.doc SSA	IC Document
Attachment A - NSHVS Cognitive Testing Final Report 12202018 (OMB).pdf Cognitive Testing Report	IC Document
Attachment C - NSHVS Follow-up non-responsive letter 040319 ICRO.docx Follow-up Non-response Letter	IC Document
Attachment D - List of expert panel meeting attendees 12202018 (OMB).docx Expert Panel List	IC Document
Attachment E - Signed Human Subjects Determination Form.pdf HS Determination	IC Document
NSHVS Project Supporting Statement B 072919 Rev.doc Part B	IC Document

IC Title:

Hospital-Based Victim Services Frame Development Project

Agency IC Tracking Number:

0920-1030-19ALS

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1030	Telephone Script	Attachment B - NSHVS Telephone Script 040319.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 4,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	4,800	4,800
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA	NSHVS Project - GenIC Statement A 040319 ICRO.doc	04/17/2019
Cognitive Testing Report	Attachment A - NSHVS Cognitive Testing Final Report 12202018 (OMB).pdf	04/17/2019
Follow-up Non-response Letter	Attachment C - NSHVS Follow-up non-responsive letter 040319 ICRO.docx	04/17/2019
Expert Panel List	Attachment D - List of expert panel meeting attendees 12202018 (OMB).docx	04/17/2019
HS Determination	Attachment E - Signed Human Subjects Determination Form.pdf	04/17/2019
Part B	NSHVS Project Supporting Statement B 072919 Rev.doc	08/05/2019

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