Counseling, Testing and Referral for Community-Based Organizations

HIV Prevention Program Evaluation and Monitoring System for Health Departments and Community-Based Organizations (PEMS)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0696 can be found here:

Documents and Forms

Document Name Document Type
Counseling, Testing and Referral for Community-Based Organizations Form and Instruction
HIV test form - page 1 Attachment 3 B HIV Test form Page 1.pdf Form and Instruction
HIV test form - page 2 Attachment 3 B HIV Test Form Page 2.pdf Form and Instruction
HIV test form - page 3 Attachment 3 B HIV Test Form Page 3.pdf Form and Instruction
HIV test form - Pacific Islands Attachment 3 C Pacific Islands HIV Test Form.pdf Form and Instruction
Attachment 3 A PEMS Home Page.docx PEMS home page IC Document

Information Collection (IC) Details

IC Title:	Counseling, Testing and Referral for Community-Based Organizations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	HIV test form - page 1	Attachment 3 B HIV Test form Page 1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	HIV test form - page 2	Attachment 3 B HIV Test Form Page 2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	HIV test form - page 3	Attachment 3 B HIV Test Form Page 3.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	HIV test form - Pacific Islands	Attachment 3 C Pacific Islands HIV Test Form.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 100

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400	120	280
Annual IC Time Burden (Hours)	12,000	5,560	6,440
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
PEMS home page	Attachment 3 A PEMS Home Page.docx	06/21/2010

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