Information Collection

Hospital-Based Victim Services Frame Development Project

IC 235734 under ICR 201703-0920-003 · OMB 0920-1030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1030 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1030 Hospital-Based Victim Services Frame Development Project Form and Instruction
0920-1030 Telephone Script Attachment B - NSHVS Telephone Script 040319.docx Form and Instruction
NSHVS Project - GenIC Statement A 040319 ICRO.doc SSA IC Document
Attachment A - NSHVS Cognitive Testing Final Report 12202018 (OMB).pdf Cognitive Testing Report IC Document
Attachment C - NSHVS Follow-up non-responsive letter 040319 ICRO.docx Follow-up Non-response Letter IC Document
Attachment D - List of expert panel meeting attendees 12202018 (OMB).docx Expert Panel List IC Document
Attachment E - Signed Human Subjects Determination Form.pdf HS Determination IC Document
NSHVS Project Supporting Statement B 072919 Rev.doc Part B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital-Based Victim Services Frame Development Project	Agency IC Tracking Number:	0920-1030-19ALS

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	0920-1030	Telephone Script	Attachment B - NSHVS Telephone Script 040319.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 4,800	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,800	4,800
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA	NSHVS Project - GenIC Statement A 040319 ICRO.doc	04/17/2019
Cognitive Testing Report	Attachment A - NSHVS Cognitive Testing Final Report 12202018 (OMB).pdf	04/17/2019
Follow-up Non-response Letter	Attachment C - NSHVS Follow-up non-responsive letter 040319 ICRO.docx	04/17/2019
Expert Panel List	Attachment D - List of expert panel meeting attendees 12202018 (OMB).docx	04/17/2019
HS Determination	Attachment E - Signed Human Subjects Determination Form.pdf	04/17/2019
Part B	NSHVS Project Supporting Statement B 072919 Rev.doc	08/05/2019

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