Information Collection

HIV-negative Patients Seeking HIV Testing and/or PrEP Services - ROI Form

IC 247947 under ICR 202411-0920-009 · OMB 0920-1357.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1357 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1357 HIV-negative Patients Seeking HIV Testing and/or PrEP Services - 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

IC Title:

HIV-negative Patients Seeking HIV Testing and/or PrEP Services - ROI Form

Agency IC Tracking Number:

0920-1357-24AQ

Is this a Common Form? No

IC Status: Unchanged

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	0920-1357	Patient Authorization to Disclose, Release and/or Obtain Protected Health Information	Att 14_GAIN ROI Form.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 850

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	850	850
Annual IC Time Burden (Hours)	142	142
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.