Att 6_Enrollment Survey B

Identification of Behavioral and Clinical Predictors of Early HIV Infection (Project DETECT)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1100 can be found here:

Documents and Forms

Document Name Document Type
Att 6_Phase 1 Enrollment Survey B.docx Other-WORD
Att 11.6_Screenshots_Phase 1 Enrollment Survey B.pdf Att 11.6_Screenshots IC Document

Information Collection (IC) Details

IC Title:	Att 6_Enrollment Survey B	Agency IC Tracking Number:	15AEZ

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
Other-WORD			Att 6_Phase 1 Enrollment Survey B.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 11.6_Screenshots	Att 11.6_Screenshots_Phase 1 Enrollment Survey B.pdf	11/12/2015

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