Information Collection

Case Report Evaluations

IC 205248 under ICR 202602-0920-009 · OMB 0920-0573.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0573 Adult HIV Confidential Case Report Form Case Report Evaluations	Form and Instruction
Form 0920-0573 Pediatric HIV Confidential Case Report Form Case Report Evaluations	Form and Instruction
Form 0920-0573 Data Elements Case Report Evaluations	Form
0920-0573 Adult HIV Confidential Case Report Form Att_3(a) Adult Case Report Form 2023 v17.pdf	Form and Instruction
0920-0573 Pediatric HIV Confidential Case Report Form Att_3(b) Pediatric Case Report Form 2023 v18.pdf	Form and Instruction
0920-0573 Data Elements Att_3c Data Elements for NHSS.pdf	Form

IC Title:

Agency IC Tracking Number:

0920-0573

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0573	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0573	Yes	Yes	Fillable Fileable
Form	0920-0573	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: SORN 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC

FR Citation: 57 FR 62812

Number of Respondents: 59

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	5,015	5,015
Annual IC Time Burden (Hours)	1,672	1,672
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.

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