Information Collection

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

IC 180694 under ICR 201007-0920-002 · OMB 0920-0696.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0696 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Counseling, Testing and Referral for Health Jurisdictions (CTR scan)	Form and Instruction
HIV test scan form - page 3 Attachment 3 B HIV Test Form Page 3.pdf	Form and Instruction
HIV test scan form - page 1 Attachment 3 B HIV Test form Page 1.pdf	Form and Instruction
HIV test scan form - page 2 Attachment 3 B HIV Test Form Page 2.pdf	Form and Instruction
HIV test scan form - Pacific Islands Attachment 3 C Pacific Islands HIV Test Form.pdf	Form and Instruction
Attachment 3 A PEMS Home Page.docx PEMS home page	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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

Documents for IC

table that charts IC Documents
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.