HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 1 HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations Form and Instruction
1 Training Survey for Health Organizations 1. Training Survey for Health Organizations.docx Form and Instruction
2 Follow Up Training Survey for Health Organizations 2. Follow Up Training Survey for Health Organizations.docx Form and Instruction
3 Advocate - Provider 6 Month Follow Up Survey for Health 3. Advocate - Provider 6 Month Follow Up Survey for Health Organizations.docx Form and Instruction
4 Collaborative Behavior Survey 4. Collaborative Behavior Survey.docx Form and Instruction
5 Health Care Response to Domestic Violence Quality Assess 5. Health Care Response to Domestic Violence Quality Assessment Program Improvement Tool.docx Form and Instruction
6a HRSA Patient Feedback Survey - English.docx 6a. HRSA Patient Feedback Survey - English.docx Form and Instruction
6b HRSA Patient Feedback Survey - Spanish 6b. HRSA Patient Feedback Survey - Spanish.docx Form and Instruction
7a Client Feedback Survey - English 7a. Client Feedback Survey - English.docx Form and Instruction
7b Client Feedback Survey - Spanish 7b. Client Feedback Survey - Spanish.docx Form and Instruction
Final Supporting Statement for Pilot on IPV Screening and Counseling in Health Centers.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Training Survey for Health Organizations	1. Training Survey for Health Organizations.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Follow Up Training Survey for Health Organizations	2. Follow Up Training Survey for Health Organizations.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Advocate - Provider 6 Month Follow Up Survey for Health Organizations	3. Advocate - Provider 6 Month Follow Up Survey for Health Organizations.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Collaborative Behavior Survey	4. Collaborative Behavior Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	Health Care Response to Domestic Violence Quality Assessment Program Improvement Tool	5. Health Care Response to Domestic Violence Quality Assessment Program Improvement Tool.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6a	HRSA Patient Feedback Survey - English.docx	6a. HRSA Patient Feedback Survey - English.docx	No		Paper Only
Form and Instruction	6b	HRSA Patient Feedback Survey - Spanish	6b. HRSA Patient Feedback Survey - Spanish.docx	No		Paper Only
Form and Instruction	7a	Client Feedback Survey - English	7a. Client Feedback Survey - English.docx	No		Paper Only
Form and Instruction	7b	Client Feedback Survey - Spanish	7b. Client Feedback Survey - Spanish.docx	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,112	Number of Respondents for Small Entity: 6

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,124	2,124
Annual IC Time Burden (Hours)	531	531
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Final Supporting Statement for Pilot on IPV Screening and Counseling in Health Centers.docx	03/11/2016

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