Information Collection

Preexposure Prophylaxis: Local Health Dept. Assessment

IC 216988 under ICR 201412-0920-011 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Preexposure Prophylaxis: Local Health Dept. Assessment	Form
PrEP Local Health Department Assessment Att B_Instrument Word Version.docx	Form
PrEP Local Health Department Assessment Att. C_Instrument Web Version.pdf	Form
1 LHD-PREP-SSA.docx Supporting Statement A	IC Document
2 LHD-PREP-SSB.docx Supporting Statement B	IC Document
Att A_LHD sample.docx Sample Selection	IC Document
Att. D_Notification E-mail.docx Notification Email	IC Document
Att. E_Reminder E-mails.docx Reminder Email	IC Document
Att. F_Reminder Call Script.docx Reminder Script	IC Document

IC Title:

Preexposure Prophylaxis: Local Health Dept. Assessment

Agency IC Tracking Number:

15AQA

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	none	PrEP Local Health Department Assessment	Att B_Instrument Word Version.docx		Yes	Yes	Fillable Fileable
Form	none	PrEP Local Health Department Assessment	Att. C_Instrument Web Version.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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 Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	1 LHD-PREP-SSA.docx	06/11/2015
Supporting Statement B	2 LHD-PREP-SSB.docx	06/11/2015
Sample Selection	Att A_LHD sample.docx	06/11/2015
Notification Email	Att. D_Notification E-mail.docx	06/11/2015
Reminder Email	Att. E_Reminder E-mails.docx	06/11/2015
Reminder Script	Att. F_Reminder Call Script.docx	06/11/2015

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