BASE -Injury Indicator

Monitoring and Reporting for the Core State Violence and Injury Prevention Program Cooperative Agreement

Documents and Forms

Document Name Document Type
Att E_Injury Indicators.010716.xlsx Other-WORD
Att E2_Inj Ind Instructions.pdf e2_Injury Indicator Spreadsheet Instructions IC Document

Information Collection (IC) Details

IC Title:	BASE -Injury Indicator	Agency IC Tracking Number:	16BZ

Is this a Common Form? No		IC Status: New

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 E_Injury Indicators.010716.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
e2_Injury Indicator Spreadsheet Instructions	Att E2_Inj Ind Instructions.pdf	03/03/2016

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