Information Collection

HIV Risk Factor Questionnaire Blood donors Control Peripheral Sites

IC 213750 under ICR 201411-0925-001 · OMB 0925-0596.

Documents and Forms

Document Name Document Type
Form 1 HIV Risk Factor Questionnaire Blood donors Control Peripheral 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIV Risk Factor Questionnaire Blood donors Control Peripheral Sites	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	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: 420	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 70 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	420	420
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	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.