Intervention Trials- Patient Exit Survey

Intervention Trials To Retain HIV-Positive Patients in Medical Care

Documents and Forms

Document Name Document Type
Form Tab 4 Intervention Trials- Patient Exit Survey Form and Instruction
Tab 4 Patient Exit Survey Tab 4 Patient Exit Survey.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Intervention Trials- Patient Exit Survey	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	Tab 4	Patient Exit Survey	Tab 4 Patient Exit Survey.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,800	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	3,600	3,600
Annual IC Time Burden (Hours)	119	119
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.