OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence

ICR 200911-0920-002 · OMB 0920-0789 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form No number Employee Survey Form and Instruction Modified Repair queued
Form No number Manager Survey Form and Instruction Modified Repair queued
SuppStatement_B_Extension_ Request_9-16-09.doc Supporting Statement B Uploaded 2009-10-21 Available
Appendix N_PUBLIC commentON FEDERAL REGISTER.htm Supplementary Document Uploaded 2009-10-21 Repair queued
Appendix M_Extension Request 60-day Federal Register Notice.pdf Supplementary Document Uploaded 2009-10-21 Repair queued
Appendix L_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document Uploaded 2009-10-21 Available
Appendix K_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document Uploaded 2009-10-21 Available
Appendix J _Workplace OMB Package_1.21.08.pdf Supplementary Document Uploaded 2009-10-21 Available
Appendix I_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document Uploaded 2009-10-21 Available
Appendix H_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document Uploaded 2009-10-21 Available
Appendix G_IPV_Workplace_OMB_Package_10_18_07.doc Supplementary Document Uploaded 2009-10-21 Available
Appendix F_IPV_Workplace_OMB_Package_10_21_07..pdf Supplementary Document Uploaded 2009-10-21 Available
Appendix D_IPV_Workplace.1.21.08.doc Supplementary Document Uploaded 2009-10-21 Available
Appendix C_IPV Workplace.1.21.08.doc Supplementary Document Uploaded 2009-10-21 Repair queued
Appendix E_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document Uploaded 2009-10-21 Available
Appendix B_IPV_Workplace._1.21.08.doc Supplementary Document Uploaded 2009-10-21 Repair queued
Appendix A_ IPV workplace OMB Package_6.7.07.doc Supplementary Document Uploaded 2009-10-21 Available
SuppStatement_A_Extension_ Request_9-21-09.doc Supporting Statement A Uploaded 2009-10-21 Available
IC Document Collections
IC IDCollectionTypeStatusForm
183664 Employee Survey Form and Instruction Modified
183663 Manager Survey Form and Instruction Modified
ICR Details
0920-0789 200911-0920-002
Historical Active 200802-0920-003
HHS/CDC
Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence
Extension without change of a currently approved collection   No
Regular
Approved without change 11/30/2009
Retrieve Notice of Action (NOA) 11/03/2009
Previous terms of clearance remain in effect.
  Inventory as of this Action Requested Previously Approved
11/30/2012 3 Months From Approved 12/31/2009
3,000 0 3,000
1,125 0 1,125
0 0 0
Intimate partner violence (IPV) affects a substantial number of Americans, and there has recently been increasing recognition of the impact it has on the workplace. The purpose of the proposed evaluation is to document in detail the workplace IPV prevention activities delivered by the company, to determine the impact of these activities on short-term and long-term outcomes, and to determine the cost-effectiveness of the program.
US Code: 42 USC 301 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  74 FR 43138 08/26/2009
74 FR 54829 10/23/2009
Yes
2
IC Title Form No. Form Name
Manager Survey No number Manager Survey
Employee Survey No number No name
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,000 3,000 0 0 0 0
Annual Time Burden (Hours) 1,125 1,125 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$293,820
Yes Part B of Supporting Statement
No
Uncollected
Uncollected
No
Uncollected
Petunia Gissendaner 4046390164
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/03/2009