Strengthening hospital-based youth violence prevention

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.