Eligibility Script for Main Study

Randomized Controlled Trial for Routine Screening for Intimate Partner Violence

Documents and Forms

Document Name Document Type
Form no number Eligibility Script for Main Study Form
no number Eligibility Script ATTACHMENT I - Eligibility script.docx Form

Information Collection (IC) Details

IC Title:	Eligibility Script for Main Study	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	no number	Eligibility Script	ATTACHMENT I - Eligibility script.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 668	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	668	668
Annual IC Time Burden (Hours)	11	11
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.