Information Collection

Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing - Study Visit Survey

IC 247950 under ICR 202209-0920-005 · OMB 0920-1357.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1357 can be found here:

Documents and Forms

Document Name Document Type
Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing - Study Visit Survey Form and Instruction
Study Visit Survey Att 11_GAIN study visit survey_screenshots_11-18-21.pdf Form and Instruction
Study Visit Survey Att 11_GAIN study visit survey_screenshots_11-18-21.pdf Form and Instruction
0920-1357 GAIN Study Visit Survey - Revised 09SEP2022 Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx Form and Instruction
0920-1357 GAIN Study Visit Survey - Revised 09SEP2022 Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participants in Prospective Study of HIV-negative Patients Seeking HIV Testing - Study Visit Survey	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 and Instruction	n/a	Study Visit Survey	Att 11_GAIN study visit survey_screenshots_11-18-21.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1357	GAIN Study Visit Survey - Revised 09SEP2022	Att 11_GAIN study visit survey_screenshots_changes accepted_082922.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 165	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	165	165
Annual IC Time Burden (Hours)	41	41
Annual IC Cost Burden (Dollars)	790	790

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.