Patient Locator Form

[NCHHSTP] mChoice: Improving PrEP Uptake and Adherence among Minority MSM through Tailored Provider Training and Adherence Assistance in Two High Priority Settings

OMB: 0920-1428

IC ID: 263487

Information Collection (IC) Details

View Information Collection (IC)

Patient Locator Form 0920-22FZ
 
Yes New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-22FZ Patient Locator Form _English Att 4b_Patient Locator Form English.docx Yes Yes Fillable Fileable
Form and Instruction 0920-22FZ Att 4b_Patient Locator Form Spanish Att 4b_Patient Locator Form Spanish.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

134 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 134 0 134 0 0 0
Annual IC Time Burden (Hours) 23 0 23 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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