Information Collection

AVERT Data Submission Form

IC 261205 under ICR 202312-0920-001 · OMB 0920-1414.

Documents and Forms

Document Name Document Type
AVERT Data Submission Form Form
ED Violence Data Form Attachment E_Proposed Change_ED Violence data form_Clean_OMB_final.xlsx Form
ED Violence Data Form Attachment E_Proposed Change_ED Violence data form_Clean_OMB_final.xlsx Form
Attachment D - Syndrome Definitions.docx Syndrome Definitions IC Document
Attachment D - Syndrome Definitions.docx Syndrome Definitions IC Document
Attachment E - AVERT_ED Violence Data Form_old orig vers edited.xlsx ED Violence Data Form - original IC Document
Attachment E - AVERT_ED Violence Data Form_old orig vers edited.xlsx ED Violence Data Form - original IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	AVERT Data Submission Form	Agency IC Tracking Number:	0920-23CU

Is this a Common Form? No		IC Status: Modified

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	n/a	ED Violence Data Form	Attachment E_Proposed Change_ED Violence data form_Clean_OMB_final.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	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	Previously Approved
Annual Number of Responses for this IC	72	12	60
Annual IC Time Burden (Hours)	36	6	30
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Syndrome Definitions	Attachment D - Syndrome Definitions.docx	07/26/2023
ED Violence Data Form - original	Attachment E - AVERT_ED Violence Data Form_old orig vers edited.xlsx	12/13/2023

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