Information Collection

Assessment of a QDS Data Collection System in HIV Prevention Program Evaluation - Spanish version

IC 193547 under ICR 200910-0920-004 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessment of a QDS Data Collection System in HIV Prevention Program Evaluation - Spanish version	Form
Eligibility screener - Spanish version 213172-B - NCHHSTP-Translation-Hkh3-QDS Baseline Survey0-s.doc	Form
Baseline survey - Spanish version 213172 - NCHHSTP-Translation-Hkh3-QDS Baseline Survey-english by client-s.doc	Form
Order 213172 CERTIFICATION Letter for NCHHSTP.pdf Certification of Translation - survey	IC Document
0920-0840-Justification for Change.docx Justification for Spanish version	IC Document
Order 213172B-Certification letter.pdf Certification of Translation - screener	IC Document

IC Title:

Assessment of a QDS Data Collection System in HIV Prevention Program Evaluation - Spanish version

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Eligibility screener - Spanish version	213172-B - NCHHSTP-Translation-Hkh3-QDS Baseline Survey0-s.doc		Yes	Yes	Fillable Fileable
Form	none	Baseline survey - Spanish version	213172 - NCHHSTP-Translation-Hkh3-QDS Baseline Survey-english by client-s.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1	0	0	0	0	0
Annual IC Time Burden (Hours)	1	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Certification of Translation - survey	Order 213172 CERTIFICATION Letter for NCHHSTP.pdf	06/24/2010
Justification for Spanish version	0920-0840-Justification for Change.docx	06/24/2010
Certification of Translation - screener	Order 213172B-Certification letter.pdf	06/24/2010

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