Information Collection

HIV/AID Rapid Testing Clinical Information Form

IC 185896 under ICR 201206-0930-001 · OMB 0930-0295.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.