Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)

A Controlled Evaluation of Expect Respect Support Groups (ERSG): Preventing and Interrupting Teen Dating Violence among At-Risk Middle and High School Students

Documents and Forms

Document Name Document Type
Att C - Intake Assessment Screening Form v1.doc Other-WORD

Information Collection (IC) Details

IC Title:	Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Att C - Intake Assessment Screening Form v1.doc		No	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: Records of Subjects in Health Promotion and Education Studies	FR Citation: 51 FR 42484

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	200	200
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.