Information Collection

[nchs] Ccqder - Nisvs

IC 263924 under ICR 202504-0920-019 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

2026-07-06 - Reinstatement without change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0222 [NCHS] CCQDER - NISVS	Form and Instruction
Form 0920-0222 NISVS Screener [NCHS] CCQDER - NISVS	Form and Instruction
Form 0920-0222 NISVS Questionnaire [NCHS] CCQDER - NISVS	Form and Instruction
Form 0920-0222 {NISVS] Respondent Data Collection Sheet (No Form) [NCHS] CCQDER - NISVS	Form
0920-0222 NISVS Screener Attachment 4_Screener_NISVS TBI.docx	Form and Instruction
0920-0222 NISVS Screener Attachment 4_Screener_NISVS TBI.docx	Form and Instruction
0920-0222 NISVS Questionnaire Attachment 1_Questions to test.docx	Form and Instruction
0920-0222 NISVS Questionnaire Attachment 1_Questions to test.docx	Form and Instruction
0920-0222 {NISVS] Respondent Data Collection Sheet (No Form) Respondent Data Collection Sheet - NISVS.docx	Form
0920-0222 {NISVS] Respondent Data Collection Sheet (No Form) Respondent Data Collection Sheet - NISVS.docx	Form
Attachment 2- Previous Use and Development.docx NISVS - Previous Use and Development	IC Document
Attachment 2- Previous Use and Development.docx NISVS - Previous Use and Development	IC Document
Attachment 3- Advertisement_NISVS TBI.docx NISVS/TBI - Advertisement	IC Document
Attachment 3- Advertisement_NISVS TBI.docx NISVS/TBI - Advertisement	IC Document
Attachment 5_Informed Consent_NISVS TBI 12.5.23.docx NISVS/TBI - Informed Consent	IC Document
Attachment 5_Informed Consent_NISVS TBI 12.5.23.docx NISVS/TBI - Informed Consent	IC Document
Attachment 6 -Respondent Distress guide.docx NISVS/TBI - Respondent Distress Guide	IC Document
Attachment 6 -Respondent Distress guide.docx NISVS/TBI - Respondent Distress Guide	IC Document
Attachment 7-Interviewer Distress Guidance_.docx NISVS/TBI - Interviewer Distress Guide	IC Document
Attachment 7-Interviewer Distress Guidance_.docx NISVS/TBI - Interviewer Distress Guide	IC Document
Attachment 8-Secondary Trauma Training by Gordon Hughes (1).pdf NISVS/TBI - Secondary Trauma Training	IC Document
Attachment 8-Secondary Trauma Training by Gordon Hughes (1).pdf NISVS/TBI - Secondary Trauma Training	IC Document
Supporting Statement A_NISVS TBI 12.8.23.docx 09s0-0222 GenIC Request Template / SSA	IC Document
Supporting Statement A_NISVS TBI 12.8.23.docx 09s0-0222 GenIC Request Template / SSA	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NCHS] CCQDER - NISVS

Agency IC Tracking Number:

0920-0222-24BR

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0222	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222	NA	No		Paper Only
Form	0920-0222	NA	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population 09-20-0164

FR Citation: 49 FR 37693

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NISVS - Previous Use and Development		12/19/2023
NISVS/TBI - Advertisement		12/19/2023
NISVS/TBI - Informed Consent		12/19/2023
NISVS/TBI - Respondent Distress Guide		12/19/2023
NISVS/TBI - Interviewer Distress Guide		12/19/2023
NISVS/TBI - Secondary Trauma Training		12/19/2023
09s0-0222 GenIC Request Template / SSA		12/19/2023

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

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