Information Collection

National Intimate Partner and Sexual Violence Surveillance System - Survey

IC 189766 under ICR 201209-0920-002 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0822 can be found here:

Documents and Forms

Document Name Document Type
National Intimate Partner and Sexual Violence Surveillance System - Survey Form
The National Intimate Partner and Sexual Violence Survey Attachment G- Survey Instrument.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	National Intimate Partner and Sexual Violence Surveillance System - Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	None	The National Intimate Partner and Sexual Violence Survey	Attachment G- Survey Instrument.doc		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,000	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	Previously Approved
Annual Number of Responses for this IC	15,000	-20,000	35,000
Annual IC Time Burden (Hours)	6,250	-8,333	14,583
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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