Information Collection

Emergency Departments Material Testing Interview

IC 183181 under ICR 201104-0920-002 · OMB 0920-0775.

Documents and Forms

Document Name Document Type
Emergency Departments Material Testing Interview Form
Emergency Department HIV Testing Interview A2a Data Collection Instruments-Routine Testing.docx Form
A5a_Consent Forms-RT_3-1-11.doc Consent for Routine Testing Interview IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Emergency Departments Material Testing Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Emergency Department HIV Testing Interview	A2a Data Collection Instruments-Routine Testing.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8	-16	24
Annual IC Time Burden (Hours)	8	-16	24
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Consent for Routine Testing Interview	A5a_Consent Forms-RT_3-1-11.doc	03/23/2011

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