OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

HIV Testing Form

IC 212075 under ICR 201406-0930-004 · OMB 0930-0343.

⚠️ Notice: This information collection may be referencing outdated material.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

2015-10-22 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
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

View Information Collection (IC)

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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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	5,000	0	5,000	0	0	0
Annual IC Time Burden (Hours)	650	0	650	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
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.