In-depth Interview Consent

Evaluation of Free Rapid HIV at-home Testing

Documents and Forms

Document Name Document Type
In-depth Interview Consent Form
Consent Consent_screenshot.docx Form
Att 4c In-depth Interview consent.docx Interview Consent Word Version IC Document

Information Collection (IC) Details

IC Title:	In-depth Interview 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	Consent_screenshot.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Interview Consent Word Version	Att 4c In-depth Interview consent.docx	03/27/2014

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