Information Collection

Att 7_Symptom and Care Survey

IC 218946 under ICR 201511-0920-006 · OMB 0920-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1100 can be found here:

Documents and Forms

Document Name Document Type
Att 7_Phase 2 HIV Symptom and Care Survey.docx Other-WORD
Att 11.7_Screenshots_Phase 2 HIV Symptom and Care Survey.pdf Att 11.7_Screenshots IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 7_Symptom and Care Survey	Agency IC Tracking Number:	15AEZ

Is this a Common Form? No		IC Status: New

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
Other-WORD			Att 7_Phase 2 HIV Symptom and Care Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 11.7_Screenshots	Att 11.7_Screenshots_Phase 2 HIV Symptom and Care Survey.pdf	11/12/2015

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