Information Collection

National Intimate Partner and Sexual Violence Screen - General Population

IC 213547 under ICR 201604-0920-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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
National Intimate Partner and Sexual Violence Screen - General Population	Form and Instruction
National Intimate Partner and Sexual Violence Screen/Sur AttE_1_DLV 7b_M5d_FINAL_NISVS3_Combined_Survey_English_07-13-2016 dropped extra SO_OMB EDIT CDC 071816.docx	Form and Instruction
National Intimate Partner and Sexual Violence Screen/Sur AttH_1_DLV 7b_FINAL_NISVS3_Combined_Survey_SPANISH_03-31-2016 dropped extra SO 072016 CDC Other Edit Clean.docx	Form and Instruction

IC Title:

National Intimate Partner and Sexual Violence Screen - General Population

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	NA	National Intimate Partner and Sexual Violence Screen/Survey (NISVS) 3.0 General Population and Military - FINAL English	AttE_1_DLV 7b_M5d_FINAL_NISVS3_Combined_Survey_English_07-13-2016 dropped extra SO_OMB EDIT CDC 071816.docx	NA	No		Fillable Fileable
Form and Instruction	NA	National Intimate Partner and Sexual Violence Screen/Survey (NISVS) 3.0 General Population and Military - FINAL Spanish	AttH_1_DLV 7b_FINAL_NISVS3_Combined_Survey_SPANISH_03-31-2016 dropped extra SO 072016 CDC Other Edit Clean.docx	NA	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 170,000

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	Previously Approved
Annual Number of Responses for this IC	170,000	85,000	85,000
Annual IC Time Burden (Hours)	8,500	4,250	4,250
Annual IC Cost Burden (Dollars)	0	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.