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Provider Survey (English Only)
Assessment of a Comprehensive HIV Clinic-based Intervention to Improve Patients' Health and Reduce Transmission Risk
OMB: 0920-1002
IC ID: 209259
OMB.report
HHS/CDC
OMB 0920-1002
ICR 201311-0920-005
IC 209259
( )
Documents and Forms
Document Name
Document Type
Provider Survey (English Only)
Form and Instruction
Appendix 12: Provider Survey (English Only)
App 12 Provider Survey.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Provider Survey (English Only)
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 and Instruction
None
Appendix 12: Provider Survey (English Only)
App 12 Provider Survey.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
120
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
480
0
480
0
0
0
Annual IC Time Burden (Hours)
80
0
80
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.