"Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)" - Pharmacy Staff Baseline Survey (Pharmacist)

Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)

Documents and Forms

Document Name Document Type
09AF_Att3a_Pharmacy Staff Baseline Survey.doc Other-WORD
09AF_Att4a_Pharmacist Consent.doc 09AF_Att4a_Pharmacist Consent IC Document
09AF_Att4b_Pharmacy Staff Consent 0920-09XX.doc 09AF_Att4b_Pharmacy Staff Consent 0920-09XX IC Document

Information Collection (IC) Details

IC Title:	"Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)" - Pharmacy Staff Baseline Survey (Pharmacist)	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
Other-WORD			09AF_Att3a_Pharmacy Staff Baseline Survey.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	Number of Respondents for Small Entity: 48

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
09AF_Att4a_Pharmacist Consent	09AF_Att4a_Pharmacist Consent.doc	09/04/2009
09AF_Att4b_Pharmacy Staff Consent 0920-09XX	09AF_Att4b_Pharmacy Staff Consent 0920-09XX.doc	09/04/2009

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