Pediatric HIV/AIDS Confidential Case Report

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⚠️ Notice: This information collection may be referencing outdated material.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
Pediatric HIV/AIDS Confidential Case Report Form and Instruction
Pediatric Case Report Form Att 3b_Pediatric 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 4b_PEDIATRIC HIV AND PERINATAL EXPOSURE CONFIDENTIAL CASE REPORT FORM_TG..pdf Technical Guidance: Pediatric Case Report and Perinatal HIV Exposure Report IC Document

Information Collection (IC) Details

IC Title:	Pediatric HIV/AIDS Confidential Case Report	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	n/a	Pediatric Case Report Form	Att 3b_Pediatric 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: 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	177	177
Annual IC Time Burden (Hours)	59	59
Annual IC Cost Burden (Dollars)	1,593	1,593

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: Pediatric Case Report and Perinatal HIV Exposure Report	Att 4b_PEDIATRIC HIV AND PERINATAL EXPOSURE CONFIDENTIAL CASE REPORT FORM_TG..pdf	06/26/2019

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