HIV/AID Rapid Testing Clinical Information Form

Rapid HIV Testing Clinical Information Form for Minority AIDS Initiative (MAI) for Ethnic Racial Minorities at Risk for Substance Use and HIV/AIDS

Documents and Forms

Document Name Document Type
Form Attachment A - HIV HIV/AID Rapid Testing Clinical Information Form Form and Instruction
Attachment A - HIV Attachment A - HIV Form Attachment A-RHT Data Collection Tool v2.pdf Form and Instruction
Attachment B-List of RHT Grantees.pdf Attachment B-List of RHT Grantees IC Document
Attachment C - List of MAITCE Grantees.doc Attachment C - List of MAITCE Grantees IC Document
Attachment D- RHT Consent Form.doc Attachment D- RHT Consent Form IC Document

Information Collection (IC) Details

IC Title:	HIV/AID Rapid Testing Clinical Information Form	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	Attachment A - HIV Form	Attachment A - HIV Form	Attachment A-RHT Data Collection Tool v2.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 64,000	Number of Respondents for Small Entity: 100

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	64,000	44,000	20,000
Annual IC Time Burden (Hours)	9,576	6,384	3,192
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment B-List of RHT Grantees	Attachment B-List of RHT Grantees.pdf	06/12/2012
Attachment C - List of MAITCE Grantees	Attachment C - List of MAITCE Grantees.doc	06/12/2012
Attachment D- RHT Consent Form	Attachment D- RHT Consent Form.doc	06/12/2012

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