CBO-HPS Referrals Category 1

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Attachment 5m

“Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients”

Referrals

This form identifies the submission of CBO-HPS referrals to CBO-OMP program staff.

Participant ID_______________________________________________________

List of CBO-HPS referrals given to the participant since last request: ______________________________________________________________________________________________________________________________________________________________________________________

Date grantee submitted the CBO-HPS Referrals to CBO-OMP program staff __/__/____.

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and sending to PS16-1604 program staff. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (xxx-xxx).