Information Collection

Pre-Hospital Stroke Systems of Care: Emergency Medical Service System (EMSS) Implementation Assessment

IC 236818 under ICR 201711-0920-012 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0879 Pre-Hospital Stroke Systems of Care: Emergency Medical Service System (EMSS) Implementation Assessment	Form and Instruction
0920-0879 Interview Guide Attachment B_Interview Guide.docx	Form and Instruction
Attachment A_Respondent Breakdown.docx Respondent Breakdown	IC Document
Attachment C_Recruitment Email.docx Recruitment Email	IC Document
Attachment D_Email Reminder.docx Email Reminder	IC Document
Attachment E_Confirmation Email.docx Confirmation Email	IC Document
Attachment F_Followup Email.docx Followup Email	IC Document
STROKE-POL-SSA final.docx SSA	IC Document
STROKE-POL-SSB.docx SSB	IC Document

IC Title:

Pre-Hospital Stroke Systems of Care: Emergency Medical Service System (EMSS) Implementation Assessment

Agency IC Tracking Number:

0920-0879-19BKU

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	0920-0879	Interview Guide	Attachment B_Interview Guide.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	48	48
Annual IC Time Burden (Hours)	72	72
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Respondent Breakdown	Attachment A_Respondent Breakdown.docx	07/05/2019
Recruitment Email	Attachment C_Recruitment Email.docx	07/05/2019
Email Reminder	Attachment D_Email Reminder.docx	07/05/2019
Confirmation Email	Attachment E_Confirmation Email.docx	07/05/2019
Followup Email	Attachment F_Followup Email.docx	07/05/2019
SSA	STROKE-POL-SSA final.docx	07/05/2019
SSB	STROKE-POL-SSB.docx	07/05/2019

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