83-c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics

0324
1121
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Enter only items that change
Current record

New record

Agency form number (s)

Clinical Indicators of Sexual Violence
in Custody- Surveillance Form
Annual reporting and recordkeeping hour
burden
Number of respondents

35

No change

Total annual responses

1,435

No change

Percent of these responses
collected electronically
Total annual hours

20

%

383

No change

%

No change

Difference
Explanation of difference
Program change
Adjustment
Annual reporting and recordkeeping cost
burden (in thousands of dollars)
Total annualized Capital/Startup costs
Total annual costs (O&M)
Total annualized cost requested
Difference
Explanation of difference
Program change
Adjustment
Other changes**

We propose revisions made to the questionnaire as a result of meeting with medical providers in recruited facilities. The
proposed changes are so minor, however, that we believe we will not need to modify the existing burden estimate of roughly
10 minutes per form. Please see attached memo for specifics.
Signature of Senior Official or designee:

** This form cannot be used to extend an expiration date.

OMB 83-C

Date:

For OIRA Use
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10/95