NHBS Screening (All Respondent Groups)

[NCHHSTP] National HIV Behavioral Surveillance System

Documents and Forms

Document Name Document Type
Form 0920-0770 NHBS Screening (All Respondent Groups) Form and Instruction
Form 0920-0770 NHBS Screening (All Respondent Groups) Form and Instruction
0920-0770 Eligibility Screener (English) Att 3a_Eligibility Screener_Eng.docx Form and Instruction
0920-0770 Eligibility Screener (English) Att 3a_Eligibility Screener_Eng.docx Form and Instruction
0920-0770 Eligibility Screener (Spanish) Att 4a_Eligibility Screener_Span.docx Form and Instruction
0920-0770 Eligibility Screener (Spanish) Att 4a_Eligibility Screener_Span.docx Form and Instruction
0920-25-0074 Eligibility Screener English Att 3a_Eligibility Screener_Eng_clean_OC.docx Form
0920-25-0074 Eligibility Screener English Att 3a_Eligibility Screener_Eng_clean_OC.docx Form
0920-25-0074 Eligibility Screener Spanish Att 4a_Eligibility_Screener_Span_clean.docx Form
0920-25-0074 Eligibility Screener Spanish Att 4a_Eligibility_Screener_Span_clean.docx Form

Information Collection (IC) Details

IC Title:	NHBS Screening (All Respondent Groups)	Agency IC Tracking Number:	0920-25-0074

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0770	Eligibility Screener (English)	Att 3a_Eligibility Screener_Eng.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0770	Eligibility Screener (Spanish)	Att 4a_Eligibility Screener_Span.docx	Yes	Yes	Fillable Fileable
Form	0920-25-0074	Eligibility Screener English	Att 3a_Eligibility Screener_Eng_clean_OC.docx	Yes	Yes	Fillable Fileable
Form	0920-25-0074	Eligibility Screener Spanish	Att 4a_Eligibility_Screener_Span_clean.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,500	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	12,500	12,500
Annual IC Time Burden (Hours)	1,042	1,042
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.