Counseling, Testing and Referral for Community-Based Organizations

HIV Prevention Program Evaluation and Monitoring System for Health Departments and Community-Based Organizations (PEMS)

⚠️ Notice: This information collection may be referencing outdated material.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 Community-Based Organizations 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

IC Title:	Counseling, Testing and Referral for Community-Based Organizations	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: 70	Number of Respondents for Small Entity: 70

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	280	280
Annual IC Time Burden (Hours)	6,440	6,440
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.