Patient Behavior Screener (for English, Spanish & Creole)

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

Documents and Forms

Document Name Document Type
Patient Behavior Screener (for English, Spanish & Creole) Form and Instruction
Appendix 6: Patient Behavior Screener (Creole) App 6 Patient beh screener (Creole).docx Form and Instruction
Appendix 4: Patient Behavior Screener (English) App 4 Patient beh screener (English).docx Form and Instruction
Appendix 5: Patient Behavior Screener (Spanish) App 5 Patient beh screener (Spanish).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Behavior Screener (for English, Spanish & Creole)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Appendix 6: Patient Behavior Screener (Creole)	App 6 Patient beh screener (Creole).docx	Yes	No	Paper Only
Form and Instruction	None	Appendix 4: Patient Behavior Screener (English)	App 4 Patient beh screener (English).docx	Yes	No	Paper Only
Form and Instruction	None	Appendix 5: Patient Behavior Screener (Spanish)	App 5 Patient beh screener (Spanish).docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,315	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,260	25,260
Annual IC Time Burden (Hours)	2,105	2,105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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