Quantitative Base Eligibility Screener

National HIV Behavioral Surveillance: Brief HIV Bio-behavioral Assessment (NHBS-BHBA)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1398 can be found here:

Documents and Forms

Document Name Document Type
Quantitative Base Eligibility Screener Form and Instruction
Quantitative Base Eligibility Screener (English) Att 3a_Quantitative Base Eligibility Screener_Eng_20220805_clean.docx Form and Instruction
Quantitative Base Eligibility Screener (English) Att 3a_Quantitative Base Eligibility Screener_Eng_20230426_clean.docx Form and Instruction
Quantitative Base Eligibility Screener (Spanish) Att 4a_Quantitative Base Eligibility Screener_Spa_20220921_clean.docx Form and Instruction
Quantitative Base Eligibility Screener (Spanish) Att 4a_Quantitative Base Eligibility Screener_Spa_20230427_clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Quantitative Base Eligibility Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	Quantitative Base Eligibility Screener (English)	Att 3a_Quantitative Base Eligibility Screener_Eng_20230426_clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Quantitative Base Eligibility Screener (Spanish)	Att 4a_Quantitative Base Eligibility Screener_Spa_20230427_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC	FR Citation: 76 FR 4458

Number of Respondents: 1,338	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,338	1,338
Annual IC Time Burden (Hours)	22	22
Annual IC Cost Burden (Dollars)	0	0

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.