Information Collection

Field Assessment of a Comprehensive Manual for Hepatitis C Counseling and Testing

IC 201009 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⚠️ Notice: This information collection may be referencing outdated material.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
Field Assessment of a Comprehensive Manual for Hepatitis C Counseling and Testing	Form
Recruitment Script Attach 1 HCV Field Assessment Recruitment Script.docx	Form
Interview Attach 3 Field Assessment Wrap-up Interview questions.docx	Form
Check-in Questions Attach 2 Field Assessment Telephone Check-in questions.docx	Form
Supporting Statement - Part B.docx Supporting Statement B	IC Document
Supporting Statement Part A.docx Supporting Statement A	IC Document
Attach 5 HCV Field Assessment Informed Consent.docx Informed Consent	IC Document

IC Title:

Field Assessment of a Comprehensive Manual for Hepatitis C Counseling and Testing

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Recruitment Script	Attach 1 HCV Field Assessment Recruitment Script.docx	No	No	Paper Only
Form	none	Interview	Attach 3 Field Assessment Wrap-up Interview questions.docx	No	No	Paper Only
Form	none	Check-in Questions	Attach 2 Field Assessment Telephone Check-in questions.docx	No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

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	240	0	0	0	0	0
Annual IC Time Burden (Hours)	70	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
Supporting Statement B	Supporting Statement - Part B.docx	02/02/2012
Supporting Statement A	Supporting Statement Part A.docx	02/02/2012
Informed Consent	Attach 5 HCV Field Assessment Informed Consent.docx	02/02/2012

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