HIV Testing Form

Co-location and Integration of HIV Prevention and Medical Care into Behavioral Health Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0343 can be found here:

Documents and Forms

Document Name Document Type
Form HIV Testing Form HIV Testing Form Form and Instruction
HIV Testing Form HIV Testing Form Attachment 1 Combined Testing Form (2).docx Form and Instruction
Attachment 5 CGI Scale.pdf CGI Scale IC Document
Attachment 6 KARNOFSKY PERFORMANCE STATUS SCALE.doc KARNOFSKY PERFORMANCE STATUS SCALE IC Document

Information Collection (IC) Details

IC Title:	HIV Testing Form	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	HIV Testing Form	HIV Testing Form	Attachment 1 Combined Testing Form (2).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	650	650
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CGI Scale	Attachment 5 CGI Scale.pdf	06/25/2014
KARNOFSKY PERFORMANCE STATUS SCALE	Attachment 6 KARNOFSKY PERFORMANCE STATUS SCALE.doc	06/25/2014

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