Randomized Controlled Trial for Routine Screening for Intimate Partner Violence

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Supplementary Quality of Life Questions	Form and Instruction	Modified	Available
Pretest Followup Questionnaire	Form and Instruction	Modified	Available
Pretest Baseline Questionnaire	Form and Instruction	Modified	Available
Supplementary Quality of Life Questions	Form and Instruction	Modified	Available
Supplementary Quality of Life Questions	Form and Instruction	Modified	Available
Main Study Follow-up Questionnaire	Form and Instruction	Modified	Available
Supplementary Quality of Life Questions	Form and Instruction	Modified	Available
Baseline Questionnaire	Form and Instruction	Modified	Available
Eligibility Script for Pretest and Main Study	Form and Instruction	Modified	Available
incentives & participation rates.htm.pdf	Supplementary Document	Uploaded 2008-12-04	Available
REQUEST FOR CHANGES.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2008-12-04	Available
Attachment D Informed Consent for Pretest.doc	Supplementary Document	Uploaded 2007-07-17	Available
Attachment E Informed Consent for Main Study.doc	Supplementary Document	Uploaded 2007-07-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
181532	Pretest Followup	Form and Instruction	Modified	Supplementary Quality of Life Questions
181532	Pretest Followup	Form and Instruction	Modified	Pretest Followup Questionnaire
181531	Pretest Baseline	Form and Instruction	Modified	Pretest Baseline Questionnaire
181531	Pretest Baseline	Form and Instruction	Modified	Supplementary Quality of Life Questions
181530	Main Study Followup	Form and Instruction	Modified	Supplementary Quality of Life Questions
181530	Main Study Followup	Form and Instruction	Modified	Main Study Follow-up Questionnaire
181529	Main Study Baseline	Form and Instruction	Modified	Supplementary Quality of Life Questions
181529	Main Study Baseline	Form and Instruction	Modified	Baseline Questionnaire
181528	Eligibility Screening for Pretest and Main Study	Form and Instruction	Modified	Eligibility Script for Pretest and Main Study

ICR Details

OMB Control No: 0920-0761	ICR Reference No: 200812-0920-002
Status: Historical Active	Previous ICR Reference No: 200708-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Randomized Controlled Trial for Routine Screening for Intimate Partner Violence
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/22/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/10/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2011	01/31/2011	01/31/2011
Responses	3,814	0	3,814
Time Burden (Hours)	718	0	718
Cost Burden (Dollars)	0	0	0

---

Abstract: Intimate partner violence (IPV) occurs frequently and has serious health, economic, and social consequences. Given the seriousness of this problem, numerous professional and health care organizations have recommended routine screening of women for IPV by health care providers in primary care settings. We propose a randomized controlled trial that will recruit 3680 women in a public obsetrics, gynecology, and family planning clinic. Women attending this clinic tend to be African American and of lower socioeconomic status. For this study (the Main Study), women will be randomly allocated to one of three arms: 1) screened for IPV, and if disclosing IPV, provided information on available IPV services; 2) not screened and all receiving information on available IPV services; or 3) a control group that will not be screened nor receive information on available IPV services.

---

Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act Research and Investigation General
   US Code: 42 USC 391 Name of Law: Public Health Service Act Prevention and Control of Injuries
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 42644	07/27/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 38837	07/13/2007
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Eligibility Screening for Pretest and Main Study	None	Eligibility Script for Pretest and Main Study
Main Study Baseline	None, None	Baseline Questionnaire ,   Supplementary Quality of Life Questions
Main Study Followup	None, None	Main Study Follow-up Questionnaire ,   Supplementary Quality of Life Questions
Pretest Baseline	None, None	Supplementary Quality of Life Questions ,   Pretest Baseline Questionnaire
Pretest Followup	None, None	Pretest Followup Questionnaire ,   Supplementary Quality of Life Questions

---

ICR Summary of Burden

table that charts list of burden

	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	3,814	3,814	0	0	0	0
Annual Time Burden (Hours)	718	718	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $482,067

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/10/2008

---