Information Collection

Male Partners - Male Partner Eligibility Questionnaire

IC 226476 under ICR 201703-0920-014 · OMB 0920-1190.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1190 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Male Partners - Male Partner Eligibility Questionnaire	Form and Instruction
ZEN Columbia - Male Partner Eligibility - Spanish Att_C7_Form de Elig_Parejas_02162017_tracked_03032017_CLEAN.docx	Form and Instruction
ZEN Columbia - Male Partner Eligibility - English 26MAY2 Att B7 - Male Partner Eligibility Screen Form_052517_CLEAN.docx	Form and Instruction

IC Title:

Male Partners - Male Partner Eligibility Questionnaire

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	ZEN Columbia - Male Partner Eligibility - Spanish	Att_C7_Form de Elig_Parejas_02162017_tracked_03032017_CLEAN.docx	NA	No		Paper Only
Form and Instruction	NA	ZEN Columbia - Male Partner Eligibility - English 26MAY2017	Att B7 - Male Partner Eligibility Screen Form_052517_CLEAN.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 - Epidemic Investigation Case Records System

FR Citation: 51 FR 42466

Number of Respondents: 2,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	208	208
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.