Interview Eligibility Screener Category 1

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

Documents and Forms

Document Name Document Type
Interview Eligibility Screener Category 1 Form
Eligibility Screener Att3a PI EligibScreenCat1.docx Form

Information Collection (IC) Details

IC Title:	Interview Eligibility Screener Category 1	Agency IC Tracking Number:

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
Form	none	Eligibility Screener	Att3a PI EligibScreenCat1.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 175	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	175	175
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.