SHIELD Model Consent (English)

[NCHHSTP] Surveillance of HIV-related service barriers among Individuals with Early or Late HIV Diagnoses (SHIELD)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1402 can be found here:

Documents and Forms

Document Name Document Type
Form 0920- SHIELD Model Consent (English) Form
0920- Model Consent (English) Att 5a_SHIELD Model Consent (English).docx Form
0920- Model Consent (English) Att 5a_SHIELD Model Consent (English).docx Form
Att 8_SHIELD Survey Screenshots.docx SHIELD Survey Screenshots IC Document
Att 8_SHIELD Survey Screenshots.docx SHIELD Survey Screenshots IC Document

Information Collection (IC) Details

IC Title:	SHIELD Model Consent (English)	Agency IC Tracking Number:	0920-23HK

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	0920-	Model Consent (English)	Att 5a_SHIELD Model Consent (English).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	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	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SHIELD Survey Screenshots	Att 8_SHIELD Survey Screenshots.docx	01/18/2023

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