Information Collection

Male Partners - Male Partner Eligibility Questionnaire

IC 226476 under ICR 201710-0920-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Male Partners - Male Partner Eligibility Questionnaire Form and Instruction
ZEN Columbia - Male Partner Eligibility - English 26MAY2 Att B7 - Male Partner Eligibility Screen Form_052517_CLEAN.docx Form and Instruction
ZEN Colombia : Male Partner Eligibility - Spanish Att C7_Form de Elig_Parejas_070617_CLEAN.DOCX Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Male Partners - Male Partner Eligibility Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	NA	ZEN Columbia - Male Partner Eligibility - English 26MAY2017	Att B7 - Male Partner Eligibility Screen Form_052517_CLEAN.docx	NA	No		Paper Only
Form	none	ZEN Colombia : Male Partner Eligibility - Spanish	Att C7_Form de Elig_Parejas_070617_CLEAN.DOCX		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: 150	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	Previously Approved
Annual Number of Responses for this IC	150	-2,350	2,500
Annual IC Time Burden (Hours)	13	-195	208
Annual IC Cost Burden (Dollars)	0	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.