Pediatric HIV Confidential Case Report Form (with Perinatal HIV Exposure information)

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⚠️ Notice: This information collection may be referencing outdated material.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
Pediatric HIV Confidential Case Report Form (with Perinatal HIV Exposure information) 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
Att_4(b) PEDIATRIC HIV CASE REPORT FORM 2023 v2_PWID edit_clean.pdf Technical Guidance: Pediatric HIV Confidential Case Report Form IC Document
Att_4(b) PEDIATRIC HIV CASE REPORT FORM 2023 v2_PWID edit_clean.pdf Technical Guidance: Pediatric HIV Confidential Case Report Form IC Document

Information Collection (IC) Details

IC Title:	Pediatric HIV Confidential Case Report Form (with Perinatal HIV Exposure information)	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	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	3,363	3,186	177
Annual IC Time Burden (Hours)	1,962	1,903	59
Annual IC Cost Burden (Dollars)	0	-1,593	1,593

Documents for IC

Title	Document	Date Uploaded
Technical Guidance: Pediatric HIV Confidential Case Report Form	Att_4(b) PEDIATRIC HIV CASE REPORT FORM 2023 v2_PWID edit_clean.pdf	09/07/2022

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