Adult HIV/AIDS Confidential Case Report

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⚠️ Notice: This information collection may be referencing outdated material.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
Adult HIV/AIDS Confidential Case Report 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
Att_4(a) ADULT HIV CONFIDENTIAL CASE REPORT FORM 2023 v2.pdf Technical Guidance: Adult HIV Confidential Case Report Form (2023) IC Document
Att_4(a) ADULT HIV CONFIDENTIAL CASE REPORT FORM 2023 v2.pdf Technical Guidance: Adult HIV Confidential Case Report Form (2023) IC Document

Information Collection (IC) Details

IC Title:	Adult HIV/AIDS Confidential Case Report	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

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	46,551	-3,835	50,386
Annual IC Time Burden (Hours)	15,517	-1,278	16,795
Annual IC Cost Burden (Dollars)	0	-453,474	453,474

Documents for IC

Title	Document	Date Uploaded
Technical Guidance: Adult HIV Confidential Case Report Form (2023)	Att_4(a) ADULT HIV CONFIDENTIAL CASE REPORT FORM 2023 v2.pdf	09/07/2022

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