Screening and Contact with Women

Micro-Finance Project for HIV Prevention

Documents and Forms

Document Name Document Type
Screening and Contact with Women Form and Instruction
Screening Form (NC) Appendix Q - Screening form_NC.doc Form and Instruction
Participant Contact Form Appendix M-Participant contact form.doc Form and Instruction
Screening Form for Women (FL) Appendix L- Screening form_Florida.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Screening and Contact with Women	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Screening Form (NC)	Appendix Q - Screening form_NC.doc	No	No	Paper Only
Form and Instruction	None	Participant Contact Form	Appendix M-Participant contact form.doc	No	No	Paper Only
Form and Instruction	None	Screening Form for Women (FL)	Appendix L- Screening form_Florida.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	55	55
Annual IC Time Burden (Hours)	10	10
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.