Information Collection

GYT: Get Yourself Tested

IC 205171 under ICR 201212-0920-006 · OMB 0920-0957.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
GYT: Get Yourself Tested	Form
GYT: Get Yourself Tested Instrument Attach 6 SurveyInstrument GYT.docx	Form
Attach 8 Screen Shots-Survey.docx Att 8 - Screenshots of Survey Instrument	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	none	GYT: Get Yourself Tested Instrument	Attach 6 SurveyInstrument GYT.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 8 - Screenshots of Survey Instrument	Attach 8 Screen Shots-Survey.docx	12/17/2012

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