SHIELD Model Consent (English)

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

Documents and Forms

Document Name Document Type
Form 0920-1402 SHIELD Model Consent (English) Form and Instruction
0920-1402 Attachment 5A SHIELD Model and Actual Consent (English) Attachment 5A SHIELD Model and Actual Consent (English).docx Form and Instruction
0920-1402 Attachment 5A SHIELD Model and Actual Consent (English) Attachment 5A SHIELD Model and Actual Consent (English).docx Form and Instruction

Information Collection (IC) Details

IC Title:	SHIELD Model Consent (English)	Agency IC Tracking Number:	0920-1402

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	0920-1402	Attachment 5A SHIELD Model and Actual Consent (English)	Attachment 5A SHIELD Model and Actual 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	Previously Approved
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
No associated records found

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