Appendix 9: Patient Exit Survey (English)

Form Approved

OMB No. 0920-New

Expiration Date XX/XX/XXXX

Assessment of a Comprehensive HIV Clinic-Based Intervention to Improve Patients’ Health and Reduce Transmission Risk

Appendix 9: Patient Exit Survey (English)

Public reporting burden of this collection of information is estimated to average 5 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-New)