Information Collection

Adult HIV/AIDS Confidential Case Report

IC 7028 under ICR 201602-0920-002 · OMB 0920-0573.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0573 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult HIV/AIDS Confidential Case Report	Form and Instruction
Att_3c_NHSS_dataelements OMB 21Dec2015.pdf	Instruction
Att 4a_Technical Guidance ACRF v11_OMB.pdf	Instruction
Adult HIV Confidential Case Report Form 2015 Att 3a_ACRF_PROOF242015.pdf	Form and Instruction
Final Att 3c_eHARS Variables (2).pdf Final Att 3c_eHARS Variables (2)	IC Document
Final Att-4a Adult Tech Guidance Vol 2 (2).pdf Final Att-4a Adult Tech Guidance Vol 2 (2)	IC Document

IC Title:

Adult HIV/AIDS Confidential Case Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	NA	Adult HIV Confidential Case Report Form 2015	Att 3a_ACRF_PROOF242015.pdf	NA	Yes	Yes	Fillable Fileable
Instruction			Att_3c_NHSS_dataelements OMB 21Dec2015.pdf	NA	Yes	Yes	Fillable Fileable
Instruction			Att 4a_Technical Guidance ACRF v11_OMB.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC

FR Citation: 57 FR 62812

Number of Respondents: 59

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	Previously Approved
Annual Number of Responses for this IC	62,599	-11,741	74,340
Annual IC Time Burden (Hours)	20,866	-3,914	24,780
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Final Att 3c_eHARS Variables (2)	Final Att 3c_eHARS Variables (2).pdf	12/19/2012
Final Att-4a Adult Tech Guidance Vol 2 (2)	Final Att-4a Adult Tech Guidance Vol 2 (2).pdf	12/19/2012

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