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RCT of POC NAT or Standard of Care for HIV-positive Patients - ROI Form
[NCHHSTP] The GAIN (Greater Access and Impact with NAT) Study: Improving HIV Diagnosis, Linkage to Care, and Prevention Services with HIV Point-of-Care Nucleic Acid Tests (NATs)
OMB: 0920-1357
IC ID: 247952
OMB.report
HHS/CDC
OMB 0920-1357
ICR 202311-0920-002
IC 247952
( )
Documents and Forms
Document Name
Document Type
Form 0920-1357
RCT of POC NAT or Standard of Care for HIV-positive Patients - ROI Form
Form and Instruction
0920-1357 Patient Authorization to Disclose, Release and/or Obtain
Att 14_GAIN ROI Form.pdf
Form and Instruction
0920-1357 Patient Authorization to Disclose, Release and/or Obtain
Att 14_GAIN ROI Form.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
RCT of POC NAT or Standard of Care for HIV-positive Patients - ROI Form
Agency IC Tracking Number:
0920-1357-24AQ
Is this a Common Form?
No
IC Status:
Modified
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
0920-1357
Patient Authorization to Disclose, Release and/or Obtain Protected Health Information
Att 14_GAIN ROI Form.pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
212
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
212
0
-121
0
0
333
Annual IC Time Burden (Hours)
35
0
-21
0
0
56
Annual IC Cost Burden (Dollars)
0
0
-1,062
0
0
1,062
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.