Participant Contact Information Form

Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles

Documents and Forms

Document Name Document Type
Participant Contact Information Form Form
Participant Contact Information Att 3e_Participant Contact Information Form.docx Form

Information Collection (IC) Details

IC Title:	Participant Contact Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Participant Contact Information	Att 3e_Participant Contact Information Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	-518	528
Annual IC Time Burden (Hours)	2	-86	88
Annual IC Cost Burden (Dollars)	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.