Information Collection

Formative Research and Tool Development - "Strengthening hospital-based youth violence prevention

IC 241652 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920-1154 Formative Research and Tool Development - "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 Att A_Informed Consent IC Document
Attachment C_Privcacy Act Hospital Based.pdf Att C_Privacy Act Hospital Based IC Document
SSA_GenIC_1154_Hospital-Based Programs 4.28.2020.docx SSA IC Document
SSB_GenIC_1154_Hospital-Based Programs 4.28.2020.docx SSB IC Document
0920-1154-20HH NOA.pdf NOA IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Formative Research and Tool Development - "Strengthening hospital-based youth violence prevention	Agency IC Tracking Number:	0920-1154-20NP

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		Yes	Yes	Paper Only

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
Att A_Informed Consent	Attachment A_Informed Consent Statement.docx	04/30/2020
Att C_Privacy Act Hospital Based	Attachment C_Privcacy Act Hospital Based.pdf	04/30/2020
SSA	SSA_GenIC_1154_Hospital-Based Programs 4.28.2020.docx	04/30/2020
SSB	SSB_GenIC_1154_Hospital-Based Programs 4.28.2020.docx	04/30/2020
NOA	0920-1154-20HH NOA.pdf	04/30/2020

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