Information Collection

2014 National Intimate Partner and Sexual Violence Screen

IC 213547 under ICR 201410-0920-019 · 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⚠️ Notice: This information collection may be referencing outdated material.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
2014 National Intimate Partner and Sexual Violence Screen	Form and Instruction
2014 National Intimate Partner and Sexual Violence Scree Att E_ Instru_NISVS_Survey_0822.docx	Form and Instruction
2014 National Intimate Partner and Sexual Violence Scree AttH_Instr_NISVS_Surv_SPANISH_0822.docx	Form and Instruction

IC Title:

2014 National Intimate Partner and Sexual Violence Screen

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Form and Instruction	None	2014 National Intimate Partner and Sexual Violence Screen/Survey-English	Att E_ Instru_NISVS_Survey_0822.docx	None	No		Fillable Fileable
Form and Instruction	None	2014 National Intimate Partner and Sexual Violence Screen/Survey-Spanish	AttH_Instr_NISVS_Surv_SPANISH_0822.docx	None	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 85,000

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	85,000	85,000
Annual IC Time Burden (Hours)	4,250	4,250
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.