Information Collection

National Intimate Partner and Sexual Violence Surveillance System (NISVSS) - Screen

IC 189767 under ICR 201209-0920-002 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0822 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment I - Advance Letter of Introduction.doc	Other-Letter of Introduction
Attachment H - RTI Confidentiality Agreement.doc Attachment H - RTI Confidentiality Agreement	IC Document

IC Title:

National Intimate Partner and Sexual Violence Surveillance System (NISVSS) - Screen

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Letter of Introduction			Attachment I - Advance Letter of Introduction.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 73,318

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	73,318	73,318
Annual IC Time Burden (Hours)	3,666	3,666
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment H - RTI Confidentiality Agreement	Attachment H - RTI Confidentiality Agreement.doc	08/30/2012

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