Information Collection

HIV Partner Services HIPEP Assessment

IC 241449 under ICR 201711-0920-012 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HIV Partner Services HIPEP Assessment	Form
Partner Services Assessment - web Attachment C - Online Assessment_ Web Version_Final.docx	Form
Partner Services Assessment - word Attachment B - Online Assessment- Word Version_Final.docx	Form
HIPEP-PS-SSA.docx Supporting Statement A	IC Document
HIPEP-PS-SSB.docx Supporting Statement B	IC Document
Attachment A - Respondent Breakdown_Final.docx Respondent Breakdown	IC Document
Attachment D_Online Assessment Invitation_Final.docx Invitation	IC Document
Attachment E_Reminder E-mail for Online Assessment_Final.docx Reminder	IC Document

IC Title:

HIV Partner Services HIPEP Assessment

Agency IC Tracking Number:

0920-0879-20IV

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	none	Partner Services Assessment - web	Attachment C - Online Assessment_ Web Version_Final.docx		Yes	Yes	Fillable Fileable
Form	none	Partner Services Assessment - word	Attachment B - Online Assessment- Word Version_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	60	60
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	HIPEP-PS-SSA.docx	04/21/2020
Supporting Statement B	HIPEP-PS-SSB.docx	04/21/2020
Respondent Breakdown	Attachment A - Respondent Breakdown_Final.docx	04/21/2020
Invitation	Attachment D_Online Assessment Invitation_Final.docx	04/21/2020
Reminder	Attachment E_Reminder E-mail for Online Assessment_Final.docx	04/21/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.