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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 220598 under ICR 201502-0915-002 · OMB 0915-0212.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

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

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

2,112 6
   
Individuals or Households
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,124 0 2,124 0 0 0
Annual IC Time Burden (Hours) 531 0 531 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.