Test-level Data

Hepatitis Testing and Linkage to Care Monitoring and Evaluation System

Documents and Forms

Document Name Document Type
Test-level Data Form and Instruction
Att4 Test Level Data Variables.docx Instruction
Att4.1 HBV- HEPTLC Data Collection Template Att4.1 HBV- HEPTLC Data Collection Template.pdf Form and Instruction
Att4.2 HCV- HEPTLC Data Collection Template Att4.2 HCV- HEPTLC Data Collection Template.pdf Form and Instruction
Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Test-level Data	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Att4.1 HBV- HEPTLC Data Collection Template	Att4.1 HBV- HEPTLC Data Collection Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Att4.2 HCV- HEPTLC Data Collection Template	Att4.2 HCV- HEPTLC Data Collection Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV	Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV.pdf	Yes	Yes	Fillable Fileable
Instruction			Att4 Test Level Data Variables.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	5,760	5,760
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.