Information Change Form

Performance Evaluation Program for Rapid HIV Testing

Documents and Forms

Document Name Document Type
Form 3 Information Change Form Form and Instruction
3 Information Change Form Attachment 6a_Information Change Form.doc Form and Instruction
Attachment 6b_ICF cover email.doc Attachment 6b_ICF cover email IC Document

Information Collection (IC) Details

IC Title:	Information Change Form	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
Form and Instruction	3	Information Change Form	Attachment 6a_Information Change Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 2

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 6b_ICF cover email	Attachment 6b_ICF cover email.doc	12/18/2009

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