Screener for One-on-One Interviews

Promoting HIV Testing among Low Income Heterosexual Young Adult Black Men

Documents and Forms

Document Name Document Type
Form 3a Screener for One-on-One Interviews Form and Instruction
3a Screening Tool 0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Screener for One-on-One Interviews	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	3a	Screening Tool	0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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