Counseling, Testing and Referral for Health Jurisdictions (CTR scan)

HIV Prevention Program Evaluation and Monitoring System for Health Departments and Community-Based Organizations (PEMS)

OMB: 0920-0696

IC ID: 180694

Information Collection (IC) Details

View Information Collection (IC)

Counseling, Testing and Referral for Health Jurisdictions (CTR scan)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction none HIV test scan form - page 3 Attachment 3 B HIV Test Form Page 3.pdf Yes Yes Fillable Fileable
Form and Instruction none HIV test scan form - page 1 Attachment 3 B HIV Test form Page 1.pdf Yes Yes Fillable Fileable
Form and Instruction none HIV test scan form - page 2 Attachment 3 B HIV Test Form Page 2.pdf Yes Yes Fillable Fileable
Form and Instruction none HIV test scan form - Pacific Islands Attachment 3 C Pacific Islands HIV Test Form.pdf Yes Yes Fillable Fileable

Health Public Health Monitoring

 

30 0
   
State, Local, and Tribal Governments
 
   100 %

  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 120 0 0 0 0 120
Annual IC Time Burden (Hours) 73,920 0 12,840 0 0 61,080
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
PEMS home page Attachment 3 A PEMS Home Page.docx 06/21/2010
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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