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⚠️ Notice: This information collection may be referencing outdated material.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 Confidential Case Report Form Att_3(a) Adult Case Report Form 2023 v17.pdf Form and Instruction
Adult HIV Confidential Case Report Form Att_3(a) Adult Case Report Form 2023 v17.pdf Form and Instruction
Pediatric HIV Confidential Case Report Form Att_3(b) Pediatric Case Report Form 2023 v18.pdf Form and Instruction
Pediatric HIV Confidential Case Report Form Att_3(b) Pediatric Case Report Form 2023 v18.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Case Report Evaluations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	None	Adult HIV Confidential Case Report Form	Att_3(a) Adult Case Report Form 2023 v17.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	None	Pediatric HIV Confidential Case Report Form	Att_3(b) Pediatric Case Report Form 2023 v18.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN 09-20-0136, 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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,015	-59	5,074
Annual IC Time Burden (Hours)	1,672	-19	1,691
Annual IC Cost Burden (Dollars)	0	-45,666	45,666

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.