HIV Partner Services HIPEP Assessment

Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.