Medical Record Abstraction Category 2

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Attachment 5l

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

Medical Record Abstraction

This form identifies the submission of medical records to CBO-OMP program staff

Medical Facility Name _______________________________________________________

Participant ID­­­­­­­­­­­­­­­­­­­­__________________________________________________________

Date submitted the data 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 medical records, gathering and maintaining the medical records, and sending to the 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).