Baseline Questionnaire

Randomized Controlled Trial for Routine Screening for Intimate Partner Violence

OMB: 0920-0761

IC ID: 181529

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Baseline Questionnaire
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form no number Baseline ATTACHMENT E.docx Yes Yes Fillable Printable

Health Illness Prevention

0920-0136 Epidemiologic Studies and Surveillance of Disease Problems  57 FR 62812

65 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 65 0 -1,162 0 0 1,227
Annual IC Time Burden (Hours) 16 0 -332 0 0 348
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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