Information Collection

HIV-negative Patients Seeking HIV Testing - Study Visit Survey

IC 247950 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⚠️ Notice: This information collection may be referencing outdated material.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 - Study Visit Survey	Form
0920-1357 Study Visit Survey (SCREENSHOTS) Att 11_GAIN study visit survey_screenshots_11-18-21.pdf	Form
0920-1357 Study Visit Survey (SCREENSHOTS) Att 11_GAIN study visit survey_screenshots_11-18-21.pdf	Form
0920-1357 GAIN Study Visit Survey - Revised 09SEP2022 (SCREENSHOTS Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx	Form
0920-1357 GAIN Study Visit Survey - Revised 09SEP2022 (SCREENSHOTS Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx	Form

IC Title:

HIV-negative Patients Seeking HIV Testing - Study Visit Survey

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	0920-1357	Study Visit Survey (SCREENSHOTS)	Att 11_GAIN study visit survey_screenshots_11-18-21.pdf		Yes	Yes	Printable Only
Form	0920-1357	GAIN Study Visit Survey - Revised 09SEP2022 (SCREENSHOTS)	Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx	NA	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	13	13
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.