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

Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.