Information Collection

Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing - ROI Form

IC 247949 under ICR 202103-0920-010 · OMB 0920-1357.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1357 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing - ROI Form	Form and Instruction
Release of Information Form Att 14_GAIN ROI Form.pdf	Form and Instruction
Release of Information Form Att 14_GAIN ROI Form.pdf	Form and Instruction

IC Title:

Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing - ROI Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Release of Information Form	Att 14_GAIN ROI Form.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 165

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	165	165
Annual IC Time Burden (Hours)	28	28
Annual IC Cost Burden (Dollars)	526	526

Documents for IC

table that charts IC Documents
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.