Reportng Test Results (completion of study)

Evaluation of Free Rapid HIV at-home Testing

Documents and Forms

Document Name Document Type
Reportng Test Results (completion of study) Form and Instruction
Reporting Home Test Results completion Reporting of Home Test Results at completion_Screenshot.docx Form and Instruction
Att 3h Reporting of Self-Test completion.docx Self-test Completion IC Document

Information Collection (IC) Details

IC Title:	Reportng Test Results (completion of study)	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 and Instruction	none	Reporting Home Test Results completion	Reporting of Home Test Results at completion_Screenshot.docx		Yes	Yes	Fillable Fileable

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 Agency Discretion
Annual Number of Responses for this IC	3,200	3,200
Annual IC Time Burden (Hours)	267	267
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Self-test Completion	Att 3h Reporting of Self-Test completion.docx	03/27/2014

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