Traumatic Brain Injury (TBI) Surveillance System

OMB 0920-1240

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.

The latest form for Traumatic Brain Injury (TBI) Surveillance System expires 2021-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

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

All Historical Document Collections

201901-0920-007 Approved without change	No material or nonsubstantive change to a currently approved collection	2019-01-24
201808-0920-003 Approved with change	New collection (Request for a new OMB Control Number)	2018-08-14

OMB Details

Eligibility Screener - Adults 18 or older

Federal Enterprise Architecture: Health - Public Health Monitoring

Form NA	Eligibility Screener - English	NA	Form and instruction
Form NA	Eligibility Screener - Spanish	NA	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.