Attachment 6
Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Date of Diagnosis Question (Script)
Public reporting burden of this collection of information is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
These questions will be asked verbally to patients upon consenting and entered into the study database by project staff.
When were you diagnosed with HIV?____________________
If you cannot remember the exact date, can you estimate the month and year?____________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ptomey, Natasha (CDC/OID/NCHHSTP) (CTR) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |