HIV Rapid Testing Form EZ WORKSHEET

Performance Evaluation Program for Rapid HIV Testing

Documents and Forms

Document Name Document Type
Form 2 HIV Rapid Testing Form EZ WORKSHEET Form and Instruction
2 HIV Rapid Testing Form EZ WORKSHEET Attachment 3a_HIV RT EZ Worksheet.doc Form and Instruction
Attachment 3b_Preshipment letter.doc Attachment 3b_Preshipment letter IC Document
Attachment 3c_HIV RT EZ cover letter.doc Attachment 3c_HIV RT EZ cover letter IC Document
Attachment 3d_MPEP General Information.doc Attachment 3d_MPEP General Information IC Document
Attachment 3e_HIV RT EZ Entry Instructions.doc Attachment 3e_HIV RT EZ Entry Instructions IC Document
Attachment 3f_WARNING HIV RT EZ 0909.doc Attachment 3f_WARNING HIV RT EZ 0909 IC Document
Attachment 3g_Donor Report.doc Attachment 3g_Donor Report IC Document
Attachment 3h_Donor Report Cover Letter.doc Attachment 3h_Donor Report Cover Letter IC Document
Attachment 3i_Password notify ltr.doc Attachment 3i_Password notify ltr IC Document
Attachment 3j_Reminder email.doc Attachment 3j_Reminder email IC Document
Attachment 3k_ Nonresponder letter-email.doc Attachment 3k_ Nonresponder letter-email IC Document
Attachment 3l_ Sample HIV RT EZ Report.pdf Attachment 3l_ Sample HIV RT EZ Report IC Document

Information Collection (IC) Details

IC Title:	HIV Rapid Testing Form EZ WORKSHEET	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	2	HIV Rapid Testing Form EZ WORKSHEET	Attachment 3a_HIV RT EZ Worksheet.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 660	Number of Respondents for Small Entity: 60

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,320	-180	1,500
Annual IC Time Burden (Hours)	220	-30	250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 3b_Preshipment letter	Attachment 3b_Preshipment letter.doc	12/17/2009
Attachment 3c_HIV RT EZ cover letter	Attachment 3c_HIV RT EZ cover letter.doc	12/17/2009
Attachment 3d_MPEP General Information	Attachment 3d_MPEP General Information.doc	12/17/2009
Attachment 3e_HIV RT EZ Entry Instructions	Attachment 3e_HIV RT EZ Entry Instructions.doc	12/17/2009
Attachment 3f_WARNING HIV RT EZ 0909	Attachment 3f_WARNING HIV RT EZ 0909.doc	12/17/2009
Attachment 3g_Donor Report	Attachment 3g_Donor Report.doc	12/17/2009
Attachment 3h_Donor Report Cover Letter	Attachment 3h_Donor Report Cover Letter.doc	12/17/2009
Attachment 3i_Password notify ltr	Attachment 3i_Password notify ltr.doc	12/17/2009
Attachment 3j_Reminder email	Attachment 3j_Reminder email.doc	12/17/2009
Attachment 3k_ Nonresponder letter-email	Attachment 3k_ Nonresponder letter-email.doc	12/17/2009
Attachment 3l_ Sample HIV RT EZ Report	Attachment 3l_ Sample HIV RT EZ Report.pdf	12/17/2009

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