Information Collection

Assessing the Accuracy of Self-Report of HIV Testing Behavior

IC 200047 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Assessing the Accuracy of Self-Report of HIV Testing Behavior Form
Patient Survey Attachment 1 Data Collection OMB.docx Form
Medical Record Abstraction Attachment 2 Medical Record Abstraction OMB.docx Form
Consent Form Attachment 3 Consent Form.docx Form
SS_PartA_TTH_Validity_MiniICR Final.doc Supporting Statement A IC Document
Supporting Statement B.docx Supporting Statement B IC Document
AuthorizationForm.pdf Authorization IC Document
IRB Certification Outcome_Letter.pdf IRB Letter IC Document
Picture Guide of QDS survey.pdf Screen shots IC Document
Poster Design 4_revised.doc Flyer IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Assessing the Accuracy of Self-Report of HIV Testing Behavior	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Medical Record Abstraction	Attachment 2 Medical Record Abstraction OMB.docx	No	No	Printable Only
Form	none	Consent Form	Attachment 3 Consent Form.docx	Yes	Yes	Fillable Fileable
Form	none	Patient Survey	Attachment 1 Data Collection OMB.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,810	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	1,810	0	0	0	0	0
Annual IC Time Burden (Hours)	600	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	SS_PartA_TTH_Validity_MiniICR Final.doc	10/31/2011
Supporting Statement B	Supporting Statement B.docx	10/31/2011
Authorization	AuthorizationForm.pdf	10/31/2011
IRB Letter	IRB Certification Outcome_Letter.pdf	10/31/2011
Screen shots	Picture Guide of QDS survey.pdf	10/31/2011
Flyer	Poster Design 4_revised.doc	11/02/2011

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