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Consent
Evaluation of Free Rapid HIV at-home Testing
OMB: 0920-1018
IC ID: 211016
OMB.report
HHS/CDC
OMB 0920-1018
ICR 201403-0920-017
IC 211016
( )
Documents and Forms
Document Name
Document Type
Consent
Form
Consent
Att 4a RCT consent form.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Consent
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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
none
Consent
Att 4a RCT consent form.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,200
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
3,200
0
3,200
0
0
0
Annual IC Time Burden (Hours)
533
0
533
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
