Information Collection

Counseling, Testing and Referral for Health Jurisdictions (CTR scan)

IC 180694 under ICR 200706-0920-006 · OMB 0920-0696.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0696 can be found here:

Documents and Forms

Document Name Document Type
Counseling, Testing and Referral for Health Jurisdictions (CTR scan) Form and Instruction
Counseling, Testing and Referral Form Attachment E. Part 1 CTR HIV Testing Form.pdf Form and Instruction
Reverse Side of CTR Form with Codes Attachment E. Part 2 CTR HIV Testing Form Codes.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Counseling, Testing and Referral for Health Jurisdictions (CTR scan)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Counseling, Testing and Referral Form	Attachment E. Part 1 CTR HIV Testing Form.pdf		Yes	Yes	Fillable Printable
Form and Instruction	None	Reverse Side of CTR Form with Codes	Attachment E. Part 2 CTR HIV Testing Form Codes.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	61,080	61,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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