Case Report Evaluations

National HIV Surveillance System (NHSS)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0573 can be found here:

Documents and Forms

Document Name Document Type
Case Report Evaluations Form and Instruction
Att_3c_NHSS_dataelements OMB 21Dec2015.pdf Instruction
Adult HIV Confidential Case Report Form 2015 Att 3a_ACRF_PROOF242015.pdf Form and Instruction
Pediatric HIV Confidential Case Report Form Att 3b_PCRF_PROOF112015.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Case Report Evaluations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	Adult HIV Confidential Case Report Form 2015	Att 3a_ACRF_PROOF242015.pdf	NA	Yes	Yes	Fillable Fileable
Instruction			Att_3c_NHSS_dataelements OMB 21Dec2015.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Pediatric HIV Confidential Case Report Form	Att 3b_PCRF_PROOF112015.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

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

Number of Respondents: 59	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	6,313	6,313
Annual IC Time Burden (Hours)	2,104	2,104
Annual IC Cost Burden (Dollars)	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.