Information Collection

[NCIPC] Violence Prevention Technical Assistance Center Participant Feedback Forms

IC 261488 under ICR 202505-0920-006 · OMB 0920-1050.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1050 can be found here:

2025-06-23 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1050 [NCIPC] Violence Prevention Technical Assistance Center Participant Feedback Forms	Form and Instruction
Form 0920-1050 Participant Feedback Form for Group Learning Events [NCIPC] Violence Prevention Technical Assistance Center Participant Feedback Forms	Form and Instruction
Form 0920-1050 Participant Feedback Form for Peer Learning Communities [NCIPC] Violence Prevention Technical Assistance Center Participant Feedback Forms	Form and Instruction
Form 0920-1050 Recipient Feedback Form for Individual TA [NCIPC] Violence Prevention Technical Assistance Center Participant Feedback Forms	Form and Instruction
Form 0920-1050 Recipient Follow Up Form for Individual TA [NCIPC] Violence Prevention Technical Assistance Center Participant Feedback Forms	Form and Instruction
0920-1050 Participant Feedback Form for Group Learning Events Att. 2 Participant Feedback Form for Group Learning Events.docx	Form and Instruction
0920-1050 Participant Feedback Form for Group Learning Events Att. 2 Participant Feedback Form for Group Learning Events.docx	Form and Instruction
0920-1050 Participant Feedback Form for Peer Learning Communities Att. 3 Participant Feedback Form for Peer Learning Communities.docx	Form and Instruction
0920-1050 Participant Feedback Form for Peer Learning Communities Att. 3 Participant Feedback Form for Peer Learning Communities.docx	Form and Instruction
0920-1050 Recipient Feedback Form for Individual TA Att. 4 Recipient Feedback Form for Individual TA.docx	Form and Instruction
0920-1050 Recipient Feedback Form for Individual TA Att. 4 Recipient Feedback Form for Individual TA.docx	Form and Instruction
0920-1050 Recipient Follow Up Form for Individual TA Att. 5 Recipient Follow Up Form for Individual TA.docx	Form and Instruction
0920-1050 Recipient Follow Up Form for Individual TA Att. 5 Recipient Follow Up Form for Individual TA.docx	Form and Instruction
Request_OMB1050_GenIC_Violence Prevention_TA center feedback _7.14.23.docx GenIC Request Template - 0920-1050	IC Document
Request_OMB1050_GenIC_Violence Prevention_TA center feedback _7.14.23.docx GenIC Request Template - 0920-1050	IC Document
Att. 1 VPTAC Privacy Act-Determination.pdf Privacy Act Determination - signed	IC Document
Att. 1 VPTAC Privacy Act-Determination.pdf Privacy Act Determination - signed	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NCIPC] Violence Prevention Technical Assistance Center Participant Feedback Forms

Agency IC Tracking Number:

0920-1050-23GX

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1050	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 725

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	725	725
Annual IC Time Burden (Hours)	131	131
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Request Template - 0920-1050		08/07/2023
Privacy Act Determination - signed		08/07/2023

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

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