Traumatic Brain Injury (TBI) Surveillance System

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Adolescent Survey - Adolescent 13-17 years of age	Form and Instruction	Unchanged	Available
Adolescent Screener - Adolescent 13-17 years of age	Form and Instruction	Unchanged	Repair queued
Adult Proxy Survey - Adults 18 or older	Form and Instruction	Unchanged	Available
Adult Proxy Screener - Adults 18 or older	Form and Instruction	Unchanged	Repair queued
Eligibility Screener - Adults 18 or older	Form and Instruction	Unchanged	Available
Non substantial change request OMB 0920_1240 TBI surveillance system.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-01-22	Available
H-1 Contact Attempt Protocols.docx	Supplementary Document	Uploaded 2018-08-10	Available
G-1 Table Shells.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-10 Intro Assent for Adol - Spanish.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-8 Consent Adult Proxy-Spanish.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-7 Consent Adult Not Proxy-Spanish.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-6 Introduction Script-Spanish.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-5 Intro-Assent for Adol-English.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-4 Consent Adult for Adol-English.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-3 Consent Adult Proxy-English.docx	Supplementary Document	Uploaded 2018-08-10	Repair queued
F-2 Consent Adult Not Proxy-English.docx	Supplementary Document	Uploaded 2018-08-10	Available
F-1 Introduction Script-English.docx	Supplementary Document	Uploaded 2018-08-10	Available
D-3 ICF IRB Approval Letter.pdf	Supplementary Document	Uploaded 2018-08-10	Available
D-1 Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2018-08-08	Available
C-1 Consultants.docx	Supplementary Document	Uploaded 2018-08-08	Available
B-1 60 Dy FRN.pdf	Supplementary Document	Uploaded 2018-08-08	Repair queued
A-2 TBI Reauthorization Act of 2014.pdf	Supplementary Document	Uploaded 2018-08-08	Available
A-1 Public Health Service Act.doc	Supplementary Document	Uploaded 2018-08-08	Available
SSB Clean - 16AOP TBI Validation 2018.7.27.docx	Supporting Statement B	Uploaded 2018-08-07	Available
SSA Clean - 16AOP TBI Validation 2018.7.27.docx	Supporting Statement A	Uploaded 2018-08-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
232649	Adolescent Survey - Adolescent 13-17 years of age	Form and Instruction	Unchanged
232648	Adolescent Screener - Adolescent 13-17 years of age	Form and Instruction	Unchanged
232647	Adult Proxy Survey - Adults 18 or older	Form and Instruction	Unchanged
232589	Adult Proxy Screener - Adults 18 or older	Form and Instruction	Unchanged
232588	Eligibility Screener - Adults 18 or older	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1240	ICR Reference No: 201901-0920-007
Status: Active	Previous ICR Reference No: 201808-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1240-19MV
Title: Traumatic Brain Injury (TBI) Surveillance System
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/14/2019
	Date Received in OIRA: 01/24/2019
Terms of Clearance: Previous terms of clearance apply: This study is approved consistent with the understanding that the data collection is designed to support exploratory research for measure development. The data collected should not be used to develop national estimates.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	08/31/2021	08/31/2021
Responses	6,503	0	6,503
Time Burden (Hours)	1,396	0	1,396
Cost Burden (Dollars)	0	0	0

---

Abstract: The Traumatic Brain Injury (TBI) Surveillance System is a case definition validation study that is designed to test the validity of a three-tiered case definition which will assess whether a TBI was sustained among adults and children during the last 12 months using parent- and self-report. Data from this study will be used to understand whether the proposed case definition and its underlying hypotheses are reflective of the data collected. In addition, the analysis should illuminate the extent to which current databases over and under estimate current TBI estimates. If validated, the new case definition will be communicated to health care professionals and researchers. This is a request to allow text message correspondence to survey participants. There is no change in burden.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: U.S. PHSA
  

Citations for New Statutory Requirements: None

---

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

---

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

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Eligibility Screener - Adults 18 or older	NA, NA	Eligibility Screener - English ,   Eligibility Screener - Spanish
Adult Proxy Screener - Adults 18 or older	NA, NA	Adult Proxy Screener - English ,   Adult Proxy Screener - Spanish
Adult Proxy Survey - Adults 18 or older	NA, NA	Adult Proxy Survey - English ,   Adult Proxy Survey - Spanish
Adolescent Screener - Adolescent 13-17 years of age	NA, NA	Adolescent Screener - English ,   Adolescent Screener - Spanish
Adolescent Survey - Adolescent 13-17 years of age	NA, NA, NA, NA	Adolescent Survey - English ,   Adolescent Survey - Spanish ,   Adolescent Survey (Web version) - English ,   Adolescent Survey (Web version) - Spanish

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,503	6,503	0	0	0	0
Annual Time Burden (Hours)	1,396	1,396	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: Submission of Traumatic Brain Injury (TBI) Surveillance System is a New ICR.

---

Annual Cost to Federal Government: $1,079,683

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  No

---

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: 01/24/2019

---