Eligibility Screening Interview Resfual Questionnaire

An assessment of the determinations of HIV risk factors for African American and Hispanic women in the southeastern United States

Documents and Forms

Document Name Document Type
APPENDIX 6 eligibility interview.doc Other-Refusal Questionnaire 6.1
APPENDIX 3-3 interview consent.doc Interview Consent IC Document

Information Collection (IC) Details

IC Title:	Eligibility Screening Interview Resfual Questionnaire	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Refusal Questionnaire 6.1			APPENDIX 6 eligibility interview.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Interview Consent	APPENDIX 3-3 interview consent.doc	07/23/2007

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