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Consent Questionnaire
Multi-site HIV Testing in Community Mental Health Settings Serving African Americans
OMB: 0920-0833
IC ID: 189384
OMB.report
HHS/CDC
OMB 0920-0833
ICR 200905-0920-003
IC 189384
( )
Documents and Forms
Document Name
Document Type
Form no number
Consent Questionnaire
Form
no number Consent questionnaire
Att 3b Consent Questionnaire.doc
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Consent Questionnaire
Agency IC Tracking Number:
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
no number
Consent questionnaire
Att 3b Consent Questionnaire.doc
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
612
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
612
0
612
0
0
0
Annual IC Time Burden (Hours)
102
0
102
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.