Information Collection

AVERT Data Submission Form

IC 261205 under ICR 202306-0920-015 · OMB 0920-1414.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1414 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-23CU AVERT Data Submission Form	Form
0920-23CU AVERT Data Submission Template_ED Violence Data Form Attachment C_AVERT Non Research Determination STARS.pdf	Form
0920-23CU AVERT Data Submission Template_ED Violence Data Form Attachment C_AVERT Non Research Determination STARS.pdf	Form
Attachment D - Syndrome Definitions.docx Syndrome Definitions	IC Document
Attachment D - Syndrome Definitions.docx Syndrome Definitions	IC Document

IC Title:

AVERT Data Submission Form

Agency IC Tracking Number:

0920-23CU

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	0920-23CU	AVERT Data Submission Template_ED Violence Data Form	Attachment C_AVERT Non Research Determination STARS.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Syndrome Definitions	Attachment D - Syndrome Definitions.docx	07/26/2023

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