Information Collection

Adult HIV/AIDS Confidential Case Report

IC 7028 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 Case Report Form Adult HIV/AIDS Confidential Case Report	Form
0920-0573 Adult Case Report Form Att_3a Adult Case Report Form Mar 2025_clean.pdf	Form
Att_4(a) ADULT HIV CONFIDENTIAL CASE REPORT FORM 2023 v2.pdf Technical Guidance: Adult HIV Confidential Case Report Form (2023)	IC Document

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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	46,551	46,551
Annual IC Time Burden (Hours)	15,517	15,517
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Technical Guidance: Adult HIV Confidential Case Report Form (2023)		09/07/2022

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].