Eligibility Screening for Pretest and Main Study

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⚠️ Notice: This information collection may be referencing outdated material.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
Eligibility Screening for Pretest and Main Study Form and Instruction
Eligibility Script for Pretest and Main Study Attachment G Eligibility Script for Pretest & Main.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Screening for Pretest and Main Study	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 and Instruction	None	Eligibility Script for Pretest and Main Study	Attachment G Eligibility Script for Pretest & Main.doc		No	No	Paper Only

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: 1,603	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,603	1,603
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	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.