Information Collection

Model Performance Evaluation Program (MPEP) For HIV Rapid Testing (HIV-RT) ENROLLMENT FORM

IC 7058 under ICR 201001-0920-002 · OMB 0920-0595.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Model Performance Evaluation Program (MPEP) For HIV Rapid Testing (HIV-RT) ENROLLMENT FORM	Form and Instruction
1 Model Performance Evaluation Program (MPEP) For HIV Rapi Attachment 5a_Enrollment Form.doc	Form and Instruction
Attachment 5b_Welcome letter.doc Attachment 5b_Welcome letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Model Performance Evaluation Program (MPEP) For HIV Rapid Testing (HIV-RT) ENROLLMENT FORM	Attachment 5a_Enrollment 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: 10

Number of Respondents for Small Entity: 2

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10	-740	750
Annual IC Time Burden (Hours)	1	-374	375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 5b_Welcome letter	Attachment 5b_Welcome letter.doc	12/17/2009

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