Information Collection

Counseling, Testing and Referral for Community-Based Organizations

IC 180696 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.