OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Positive Health Check Evaluation Trial

OMB 0920-1211 ยท HHS/CDC.

OMB 0920-1211

The purpose of this data collection is to evaluate the effectiveness of Positive Health Check (PHC), an online tool created by RTI and CDC that delivers tailored evidence based prevention messages to HIV positive patients, on improving clinical outcomes and retention in care of HIV positive patients with unsuppressed viral loads.

The latest form for Positive Health Check Evaluation Trial expires 2020-12-31 and is listed under ICR 201706-0920-012.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
PHC Non-Labor Cost QuestionnaireForm and Instruction
Standard of Care QuestionnaireForm and Instruction
PHC Labor Cost QuestionnaireForm and Instruction
Non-Research Labor Cost QuestionnaireForm and Instruction
Clinic Staff Qualitative Interview GuideForm and Instruction
Clinic Staff SurveyForm and Instruction
Electronic Medical Records (EMR)Form and Instruction
PHC Tailoring QuestionsForm and Instruction
Date of Diagnosis QuestionForm and Instruction
Att 16 PHC Sample Patient Handout.pdf Supplementary Document
Att 15 Recruitment Scripts for Clinic Staff CLEAN 12.13.17.._.docx Supplementary Document
Att 9 Consent Form CLEAN 12.13.17.docx Supplementary Document
Att 5 IRB approval.pdf Supplementary Document
Att 4 Positive Health Check Screenshots.5.11.17docx.docx Supplementary Document
Att 3 References (1) CLEAN 12.13.17.docx Supplementary Document
Att 2 60 Day FRN.pdf Supplementary Document
Att 1 Auth legislation.docx Supplementary Document
PHC SSB CLEAN CH 12.15.17 FINAL.DOCXSupporting Statement B
SS A 12.15.17 CH CLEAN_FINAL .docxSupporting Statement A
PHC Non-Labor Cost Questionnaire Form and Instruction
Standard of Care Questionnaire Form and Instruction
PHC Labor Cost Questionnaire Form and Instruction
Non-Research Labor Cost Questionnaire Form and Instruction
Clinic Staff Qualitative Interview Guide Form and Instruction
Clinic Staff Survey Form and Instruction
Electronic Medical Records (EMR) Form and Instruction
PHC Tailoring Questions Form and Instruction
Date of Diagnosis Question Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
201706-0920-012 New collection (Request for a new OMB Control Number) 2017-07-05 Approved with change

OMB Details

Date of Diagnosis Question

Federal Enterprise Architecture: Health - Illness Prevention

Information collection instruments
FormNameElectronic accessType
Form NADate of Diagnosis Question - Att 6NAForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.