Information Collection

HIV testing & prevention services template -Community-Based Organization

IC 217851 under ICR 202605-0920-005 · OMB 0920-0696.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-26-0201 Att 3A_HIV Testing and Prevention Services Template- CBO HIV testing & prevention services template -Community-Based Organization	Form
0920-26-0201 Att 3A_HIV Testing and Prevention Services Template- CBO Att 3A_HIV Testing and Prevention Services Template for HDs and most CBOs_Revised.pdf	Form
Att 5B NHME Variables Options July 2018.docx Data Variable Options	IC Document

IC Title:

Agency IC Tracking Number:

0920-26-0201

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	0920-26-0201				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 114

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	228	-72	300
Annual IC Time Burden (Hours)	520	-15,680	16,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Variable Options		08/20/2018

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

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