Information Collection

Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing and/or PrEP Services - Study Visit Survey

IC 247948 under ICR 202209-0920-005 · OMB 0920-1357.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1357 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing and/or PrEP Services - Study Visit Survey	Form and Instruction
Study Visit Survey Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing and/or PrEP Services - Study Visit Survey	Form and Instruction
Form 0920-1357 GAIN Study Visit Survey - Revised 09SEP2022 Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing and/or PrEP Services - Study Visit Survey	Form and Instruction
Study Visit Survey Att 11_GAIN study visit survey_screenshots_11-18-21.pdf	Form and Instruction
Study Visit Survey Att 11_GAIN study visit survey_screenshots_11-18-21.pdf	Form and Instruction
0920-1357 GAIN Study Visit Survey - Revised 09SEP2022 Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx	Form and Instruction
0920-1357 GAIN Study Visit Survey - Revised 09SEP2022 Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx	Form and Instruction

IC Title:

Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing and/or PrEP Services - Study Visit Survey

Agency IC Tracking Number:

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	n/a	Study Visit Survey	Att 11_GAIN study visit survey_screenshots_11-18-21.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1357	GAIN Study Visit Survey - Revised 09SEP2022	Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,530

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	1,530	1,530
Annual IC Time Burden (Hours)	383	383
Annual IC Cost Burden (Dollars)	7,321	7,321

Documents for IC

table that charts IC Documents
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.