Information Collection

Community-Based Organization HIV Prevention Survey

IC 243303 under ICR 202210-0920-004 · OMB 0920-1321.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Community-Based Organization HIV Prevention Survey	Form and Instruction
CBO HIV Prevention Survey Att 5a_CBO Survey Instrument_10172022_clean.docx	Form and Instruction
CBO HIV Prevention Survey Att 5a_CBO Survey Instrument_10172022_clean.docx	Form and Instruction
Att 5b_Survey Instrument.pdf CBO HIV Prevention Survey Screenshots	IC Document
Att 5b_Survey Instrument.pdf CBO HIV Prevention Survey Screenshots	IC Document
Att 5a_CBO Survey Instrument_10172022_tracked.docx Survey with Oct 2022 Monkeypox questions in tracked-changes	IC Document
Att 5a_CBO Survey Instrument_10172022_tracked.docx Survey with Oct 2022 Monkeypox questions in tracked-changes	IC Document

IC Title:

Agency IC Tracking Number:

0920-20HR

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	None	CBO HIV Prevention Survey	Att 5a_CBO Survey Instrument_10172022_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 330

Number of Respondents for Small Entity: 30

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	330	0	330
Annual IC Time Burden (Hours)	193	28	165
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CBO HIV Prevention Survey Screenshots	Att 5b_Survey Instrument.pdf	08/25/2020
Survey with Oct 2022 Monkeypox questions in tracked-changes	Att 5a_CBO Survey Instrument_10172022_tracked.docx	10/17/2022

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