Baseline Assessment

Evaluation of TransLife Center (TLC): A Locally-Developed Combination Prevention Intervention for Transgender Women at High Risk of HIV Infection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1246 can be found here:

Documents and Forms

Document Name Document Type
Baseline Assessment Form
TLC Baseline Assessment Screen Shot.pdf Other-Example Screen Shots of a Comp
TLC Baseline Assessment Att 4c_TLC Baseline Assessment_23Aug2018.docx Form

Information Collection (IC) Details

IC Title:	Baseline Assessment	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	n/a	TLC Baseline Assessment	Att 4c_TLC Baseline Assessment_23Aug2018.docx		Yes	Yes	Fillable Fileable
Other-Example Screen Shots of a Completed Baseline Assessment			TLC Baseline Assessment Screen Shot.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC	FR Citation: 57 FR 62812

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	1,826	1,826

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.