Case Report Evaluations

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⚠️ Notice: This information collection may be referencing outdated material.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
Case Report Evaluations Form and Instruction
Adult HIV Case Report Form Att 3a_Adult Case Report Form 2019_v4_OMB_rev18Jun19.pdf Form and Instruction
Adult HIV Case Report Form Att 3a_Adult Case Report Form 2019_v4_OMB_rev18Jun19.pdf Form and Instruction
Pediatric HIV Case Report Form Att 3b_Pediatric Case Report Form 2019_v4_OMB_rev18Jun19.pdf Form and Instruction
Pediatric HIV 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 3c_NHSS_dataelements OMB_20190313_clean.pdf Reference: Data Elements for the National HIV Surveillance System IC Document

Information Collection (IC) Details

IC Title:	Case Report Evaluations	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	Adult HIV Case Report Form	Att 3a_Adult Case Report Form 2019_v4_OMB_rev18Jun19.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Pediatric HIV 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	5,074	5,074
Annual IC Time Burden (Hours)	1,691	1,691
Annual IC Cost Burden (Dollars)	45,666	45,666

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

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