Information Collection

Ryan White HIV/AIDS Program Outcomes and Expanded Insurance Coverage Guides

IC 226197 under ICR 201703-0906-001 · OMB 0906-0030.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Ryan White HIV/AIDS Program Outcomes and Expanded Insurance Coverage Guides	Form
1 Medical chart/record abstraction sample selection guide Medical chart abstraction guide.docx	Form
2 Focus Groups Focus group guide .docx	Form and Instruction
3 Site interviews (site administrators) SIte interview guide .docx	Form and Instruction
4 Site Survey Site survey.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Medical chart/record abstraction sample selection guide	Medical chart abstraction guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Focus Groups	Focus group guide .docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Site interviews (site administrators)	SIte interview guide .docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Site Survey	Site survey.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 440

Number of Respondents for Small Entity: 20

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	440	440
Annual IC Time Burden (Hours)	418	418
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.