Information Collection

AVERT Data Submission Form

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

0920-23CU

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.