Information Collection

Phase 2 HIV Symptom and Care Survey

IC 218946 under ICR 202112-0920-002 · OMB 0920-1100.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1100 Phase 2 HIV Symptom and Care Survey	Form and Instruction
Form 0920-1100 Att 9a_Phase 2 HIV Symptom and Care Survey (English) Phase 2 HIV Symptom and Care Survey	Form and Instruction
Form 0920-1100 Att 9b_Phase 2 HIV Symptom and Care Survey (Spanish) Phase 2 HIV Symptom and Care Survey	Form and Instruction
0920-1100 Att 9a_Phase 2 HIV Symptom and Care Survey (English) Att 9a_Phase 2 HIV Symptom and Care Survey (English).docx	Form and Instruction
0920-1100 Att 9a_Phase 2 HIV Symptom and Care Survey (English) Att 9a_Phase 2 HIV Symptom and Care Survey (English).docx	Form and Instruction
0920-1100 Att 9b_Phase 2 HIV Symptom and Care Survey (Spanish) Att 9b_Phase 2 HIV Symptom and Care Survey (Spanish).docx	Form and Instruction
0920-1100 Att 9b_Phase 2 HIV Symptom and Care Survey (Spanish) Att 9b_Phase 2 HIV Symptom and Care Survey (Spanish).docx	Form and Instruction
Att 12a_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey.pdf Att 12a_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey	IC Document
Att 12a_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey.pdf Att 12a_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey	IC Document
Att 12b_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey (Spanish).pdf Att 12b_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey (Spanish)	IC Document
Att 12b_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey (Spanish).pdf Att 12b_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey (Spanish)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Phase 2 HIV Symptom and Care Survey

Agency IC Tracking Number:

0920-1100

Is this a Common Form? No

IC Status: Modified

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	0920-1100				Yes	Yes	Fillable Fileable
Form and Instruction	0920-1100				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 12a_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey		12/07/2021
Att 12b_Screenshots_REDCaP_Phase 2 HIV Symptom and Care Survey (Spanish)		12/07/2021

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

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