Information Collection

Strengthening hospital-based youth violence prevention

IC 239851 under ICR 201912-0920-003 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1154 Strengthening hospital-based youth violence prevention	Form and Instruction
0920-1154 Interview Guide Attachment B_Interview Guide.docx	Form and Instruction
Attachment A_Informed Consent Statement.docx Informed Consent Statement	IC Document
Attachment C_Privcacy Act Hospital Based (1).pdf Privacy Act	IC Document
SSA_GenIC_1154_Hospital-Based Programs 2.6.20 (1).docx SSA	IC Document
SSB_GenIC_1154_Hospital-Based Programs 2.6.20.docx SSB	IC Document

IC Title:

Strengthening hospital-based youth violence prevention

Agency IC Tracking Number:

0920-20HH

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	0920-1154	Interview Guide	Attachment B_Interview Guide.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45

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	45	45
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Informed Consent Statement	Attachment A_Informed Consent Statement.docx	02/06/2020
Privacy Act	Attachment C_Privcacy Act Hospital Based (1).pdf	02/06/2020
SSA	SSA_GenIC_1154_Hospital-Based Programs 2.6.20 (1).docx	02/06/2020
SSB	SSB_GenIC_1154_Hospital-Based Programs 2.6.20.docx	02/06/2020

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