HIV Incidence Surveillance (HIS)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0573 HIV Incidence Surveillance (HIS) Form and Instruction
0920-0573 HIV Incidence Surveillance (HIS) Att 3a_Adult Case Report Form 2019_v4_OMB_rev18Jun19.pdf Form and Instruction
Att 3c_NHSS_dataelements OMB_20190313_clean.pdf Reference: Data Elements for the National HIV Surveillance System IC Document
Att 4c_TECHNICAL GUIDANCE DUPLICATE REVIEW FINAL.pdf Technical Guidance: Duplicate Review IC Document

Information Collection (IC) Details

IC Title:	HIV Incidence Surveillance (HIS)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	0920-0573	HIV Incidence Surveillance (HIS)	Att 3a_Adult Case Report Form 2019_v4_OMB_rev18Jun19.pdf		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: 7	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	15,974	15,974
Annual IC Time Burden (Hours)	1,331	1,331
Annual IC Cost Burden (Dollars)	143,766	143,766

Documents for IC

Title	Document	Date Uploaded
Reference: Data Elements for the National HIV Surveillance System	Att 3c_NHSS_dataelements OMB_20190313_clean.pdf	06/26/2019
Technical Guidance: Duplicate Review	Att 4c_TECHNICAL GUIDANCE DUPLICATE REVIEW FINAL.pdf	06/26/2019

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