AVERT Data Submission Form

[NCIPC] Advancing Violence Epidemiology in Real-Time (AVERT)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.