Screener and Contact Forms

Nurse Delivered Risk Reduction Intervention for HIV-Positive Women In the South

Documents and Forms

Document Name Document Type
Form 1 Screener and Contact Forms Form and Instruction
1 Screener and Contact Forms 0920-New_att3_Screener.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Screener and Contact Forms	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Screener and Contact Forms	0920-New_att3_Screener.doc		No		Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 550	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	550	550
Annual IC Time Burden (Hours)	92	92
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.