Information Collection

HIV-negative MSM Screener-English

IC 219086 under ICR 201511-0920-012 · OMB 0920-1111.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-015AGK HIV-negative MSM Screener-English	Form and Instruction
0920-015AGK Att 3a HIV-Neg MSM Screener_English Att 3a HIV-Neg MSM Screener_English.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

15AGK

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	0920-015AGK	Att 3a HIV-Neg MSM Screener_English	Att 3a HIV-Neg MSM Screener_English.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

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: 0 %

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)	18	18
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.