Intervention Trials- Patient Eligibility Screener

Intervention Trials To Retain HIV-Positive Patients in Medical Care

Documents and Forms

Document Name Document Type
Form Tab 6 Intervention Trials- Patient Eligibility Screener Form
Tab 6 Patient Eligibility Screener Tab 6 Eligibility Screening Form.doc Form
Tab 5 Eligibility Criteria.doc Patient Eligibility Criteria IC Document

Information Collection (IC) Details

IC Title:	Intervention Trials- Patient Eligibility Screener	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	Tab 6	Patient Eligibility Screener	Tab 6 Eligibility Screening Form.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	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	3,000	3,000
Annual IC Time Burden (Hours)	249	249
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Patient Eligibility Criteria	Tab 5 Eligibility Criteria.doc	08/04/2009

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