Information Collection

NHBS Behavioral Assessment (MSM)

IC 182203 under ICR 202603-0920-004 · OMB 0920-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0770 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-26-0109 Behavioral Assessment MSM_English NHBS Behavioral Assessment (MSM) Form
Form 0920-26-0109 Behavioral Assessment MSM_Spanish NHBS Behavioral Assessment (MSM) Form
0920-26-0109 Behavioral Assessment MSM_English Att 3b_Behavioral Assessment MSM_Eng.docx Form
0920-26-0109 Behavioral Assessment MSM_Spanish Att 4b_Behavioral Assessment MSM_Span.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NHBS Behavioral Assessment (MSM)	Agency IC Tracking Number:	0920-26-0109

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	0920-26-0109	Behavioral Assessment MSM_English	Att 3b_Behavioral Assessment MSM_Eng.docx		Yes	Yes	Fillable Fileable
Form	0920-26-0109	Behavioral Assessment MSM_Spanish	Att 4b_Behavioral Assessment MSM_Span.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems. HHS/CDC	FR Citation: 57 FR 62812

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,500	167	3,333
Annual IC Time Burden (Hours)	758	-576	1,334
Annual IC Cost Burden (Dollars)	0	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.

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