Eligibility Screener

Web-based Approaches to Reach Black or African American and Hispanic/Latino MSM for HIV Testing and Prevention Services

Documents and Forms

Document Name Document Type
Form 0920- Eligibility Screener Form and Instruction
0920- Eligibility Screener Att 3b_Registration contact info.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Screener	Agency IC Tracking Number:	0920-19BG

Is this a Common Form? No		IC Status: Unchanged

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	0920-	Eligibility Screener	Att 3b_Registration contact info.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,333	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,333	3,333
Annual IC Time Burden (Hours)	111	111
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.