Information Collection

Guest HIV Test Result Survey

IC 237106 under ICR 201907-0920-005 · OMB 0920-1284.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1284 can be found here:

Documents and Forms

Document Name Document Type
Form 0920- Guest HIV Test Result Survey Form and Instruction
0920- Guest HIV Test Result Survey Att 3h_Guest HIV Test Results.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Guest HIV Test Result Survey	Agency IC Tracking Number:	0920-19BG

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
Form and Instruction	0920-	Guest HIV Test Result Survey	Att 3h_Guest HIV Test Results.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 667	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	667	667
Annual IC Time Burden (Hours)	56	56
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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