Att 9_Provider Screener

Formative Research to Develop HIV Social Marketing Campaigns for Healthcare Providers

Documents and Forms

Document Name Document Type
Att9-Provider Screener.docx Other-WORD

Information Collection (IC) Details

IC Title:	Att 9_Provider Screener	Agency IC Tracking Number:	0920-1182

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Att9-Provider Screener.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,138	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,138	1,138
Annual IC Time Burden (Hours)	190	190
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.