Information Collection

Survey on Sexual Violence

IC 12623 under ICR 201103-1121-001 · OMB 1121-0292.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0292 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSV-1 Survey on Sexual Violence	Form
SSV-1 SSV Federal Bureau of Prisons Summary Form ssv1_final.pdf	Form
SSV-2 SSV State Prison Systems Summary Form ssv2_final.pdf	Form
SSV-3 SSV Local Jail Jurisdictions Summary Form ssv3_final.pdf	Form
SSV-4 SSV Other Correctional Facilities Summary Form ssv4_final.pdf	Form
SSV-5 SSV State Juvenile Systems Summary Form ssv5_final.pdf	Form
SSV-6 SSV Locally or Privately-Operated Juvenile Facilities Su ssv6_final.pdf	Form
SSV IA SSV Incident Form Adult ssvia_fillable.pdf	Form
SSV IJ SSV Incident Form Juveniles ssvij_fillable.pdf	Form

IC Title:

Survey on Sexual Violence

Agency IC Tracking Number:

BJS

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSV-1	SSV Federal Bureau of Prisons Summary Form	ssv1_final.pdf	Yes	Yes	Fillable Fileable
Form	SSV-2	SSV State Prison Systems Summary Form	ssv2_final.pdf	Yes	Yes	Fillable Fileable
Form	SSV-3	SSV Local Jail Jurisdictions Summary Form	ssv3_final.pdf	Yes	Yes	Fillable Fileable
Form	SSV-4	SSV Other Correctional Facilities Summary Form	ssv4_final.pdf	Yes	Yes	Fillable Fileable
Form	SSV-5	SSV State Juvenile Systems Summary Form	ssv5_final.pdf	Yes	Yes	Fillable Fileable
Form	SSV-6	SSV Locally or Privately-Operated Juvenile Facilities Summary Form	ssv6_final.pdf	Yes	Yes	Fillable Fileable
Form	SSV IA	SSV Incident Form Adult	ssvia_fillable.pdf	Yes	Yes	Fillable Fileable
Form	SSV IJ	SSV Incident Form Juveniles	ssvij_fillable.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,481

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,481	1,481
Annual IC Time Burden (Hours)	992	992
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.