Adult HIV/AIDS Confidential Case Report

Attachment 3 (a)
Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance OMB No. 0920-0573

Adult HIV/AIDS Confidential Case Report Form

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Form Approved
OMB No. 0920-0573
Expiration Date XX/XX/20XX
Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance
Adult HIV/AIDS Confidential Case Report Form

Public reporting burden of this collection of information is
estimated to average 20 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; Attn: OMB-PRA (0920-0573)

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