Information Collection

HIV Risk Factor Questionnaire Blood donors Case Primary Sites

IC 213747 under ICR 201411-0925-001 · OMB 0925-0596.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 HIV Risk Factor Questionnaire Blood donors Case Primary Sites	Form and Instruction
1 HIV Risk Factor Questionnaire English Attachment_1.1_HIV_Risk_Factor_Q_English_11_2014_V_8.0.docx	Form and Instruction
2 HIV Questionaire Informed Consent Attachment_2_HIV_Questionaire_Informed Consent Form_11_2014_V_6.0.docx	Form

IC Title:

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	1	HIV Risk Factor Questionnaire English	Attachment_1.1_HIV_Risk_Factor_Q_English_11_2014_V_8.0.docx		Yes	Yes	Fillable Fileable
Form	2	HIV Questionaire Informed Consent	Attachment_2_HIV_Questionaire_Informed Consent Form_11_2014_V_6.0.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 210

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	210	210
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.