Pretest Baseline

Randomized Controlled Trial for Routine Screening for Intimate Partner Violence

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0761 can be found here:

Documents and Forms

Document Name Document Type
Pretest Baseline Form and Instruction
Supplementary Quality of Life Questions Attachment L-SF-12v2 Standard.pdf Form and Instruction
Pretest Baseline Questionnaire Attachment H Pretest Baseline Questionnaire.doc Form and Instruction
Attachment D Informed Consent for Pretest.doc Informed Consent for Pretest IC Document

Information Collection (IC) Details

IC Title:	Pretest Baseline	Agency IC Tracking Number:

Is this a Common Form? No		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	None	Supplementary Quality of Life Questions	Attachment L-SF-12v2 Standard.pdf		Yes	Yes	Fillable Printable
Form and Instruction	None	Pretest Baseline Questionnaire	Attachment H Pretest Baseline Questionnaire.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 0920-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 65	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	65	65
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Informed Consent for Pretest	Attachment D Informed Consent for Pretest.doc	07/17/2007

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