OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum

OMB 0920-1361 · HHS/CDC.

OMB 0920-1361

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Post-Consultation Questionnaire (screenshots)Form and Instruction
Post-Consultation QuestionnaireForm and Instruction
Clinician Consultation Guide (screenshots)Form and Instruction
Peer-to-Peer Clinician Consultation [Provider Participants]Form and Instruction
Clinician Consultation Guide (screenshots)Form and Instruction
Peer-to-Peer Clinician Consultation [HIV Expert Consultants]Form and Instruction
Referral ScriptForm and Instruction
Phase II InterviewForm and Instruction
Phase II Interview for Participants of Patient-level InterventionForm and Instruction
Referral ScriptForm and Instruction
Phase I InterviewForm and Instruction
Phase I Interview for Participants of Patient-level InterventionForm and Instruction
PositiveLinks Verbal Consent and EnrollmentForm and Instruction
PositiveLinks Verbal Consent and EnrollmentForm and Instruction
HIPAA AuthorizationForm
HIPAA Authorization [Control Patient Participants]Form
HIPAA AuthorizationForm
HIPAA Authorization [Patients of Providers in Provider-level Intervention]Form
HIPAA AuthorizationForm
HIPAA Authorization [Participants of Patient-level Intervention]Form
Verbal Consent [Control Participants]Form and Instruction
Verbal Consent [Control Patient Participants]Form and Instruction
Verbal Consent [Control Participants]Form and Instruction
Verbal Consent [Patients of Providers in Provider-level Intervention]Form and Instruction
Verbal Consent [Provider Participants]Form and Instruction
Verbal Consent [Providers]Form and Instruction
Verbal Consent [Participants]Form and Instruction
Verbal Consent [Participants of Patient-level Intervention]Form and Instruction
SSA_AIMS_101821.docxSupporting Statement A
Att 19_60-Day FRN.pdf Supplementary Document
Att 18_Institutional Review Board approval letter.pdf Supplementary Document
Att 17b_Certified letter_control participants.docx Supplementary Document
Att 17a_Certified letter_participants.docx Supplementary Document
Att 16_Privacy Impact Assessment.pdf Supplementary Document
Att 15_PositiveLinks data elements.docx Supplementary Document
Att 12b_PositiveLinks Program and Service Agreement letter.docx Supplementary Document
Att 7c_Contact protocol_control participants.docx Supplementary Document
Att 7b_Contact protocol_provider participants.docx Supplementary Document
Att 7a_Contact protocol_participants.docx Supplementary Document
Att 6b_Study information sheet_provider participants.docx Supplementary Document
Att 6a_Study information sheet _providers of participants.docx Supplementary Document
Att 5d_Courtesy notification letter to providers of participants.docx Supplementary Document
Att 5c_Introductory letter_control participants.docx Supplementary Document
Att 5b_Introductory letter_provider participants.docx Supplementary Document
Att 5a_Introductory letter_participants.docx Supplementary Document
Att 4_Virginia Care Marker Data abstraction.docx Supplementary Document
Att 3_Virginia Medicaid data abstraction.docx Supplementary Document
Att 2_Technical Appendix_09292021.docx Supplementary Document
Att 1_Authorizing legislation.pdf Supplementary Document
SSB_AIMS_092921.docxSupporting Statement B
Post-Consultation Questionnaire Other-WORD version of content to facilitate review
Post-Consultation Questionnaire Form and Instruction
Post-Consultation Questionnaire Form and Instruction
Peer-to-Peer Clinician Consultation [Provider Participants] Other-WORD version of content to facilitate review
Peer-to-Peer Clinician Consultation [Provider Participants] Form and Instruction
Peer-to-Peer Clinician Consultation [Provider Participants] Form and Instruction
Peer-to-Peer Clinician Consultation [HIV Expert Consultants] Other-WORD version of content to facilitate review
Peer-to-Peer Clinician Consultation [HIV Expert Consultants] Form and Instruction
Peer-to-Peer Clinician Consultation [HIV Expert Consultants] Form and Instruction
Phase II Interview for Participants of Patient-level Intervention Form and Instruction
Phase II Interview for Participants of Patient-level Intervention Form and Instruction
Phase II Interview for Participants of Patient-level Intervention Form and Instruction
Phase I Interview for Participants of Patient-level Intervention Form and Instruction
Phase I Interview for Participants of Patient-level Intervention Form and Instruction
Phase I Interview for Participants of Patient-level Intervention Form and Instruction
PositiveLinks Verbal Consent and Enrollment Form and Instruction
PositiveLinks Verbal Consent and Enrollment Form and Instruction
HIPAA Authorization [Control Patient Participants] Form
HIPAA Authorization [Control Patient Participants] Form
HIPAA Authorization [Patients of Providers in Provider-level Intervention] Form
HIPAA Authorization [Patients of Providers in Provider-level Intervention] Form
HIPAA Authorization [Participants of Patient-level Intervention] Form
HIPAA Authorization [Participants of Patient-level Intervention] Form
Verbal Consent [Control Patient Participants] Form and Instruction
Verbal Consent [Control Patient Participants] Form and Instruction
Verbal Consent [Patients of Providers in Provider-level Intervention] Form and Instruction
Verbal Consent [Patients of Providers in Provider-level Intervention] Form and Instruction
Verbal Consent [Providers] Form and Instruction
Verbal Consent [Providers] Form and Instruction
Verbal Consent [Participants of Patient-level Intervention] Form and Instruction
Verbal Consent [Participants of Patient-level Intervention] Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202109-0920-005 New collection (Request for a new OMB Control Number) 2021-10-19 Approved without change