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Follow-up Survey for RCT
Evaluation of Free Rapid HIV at-home Testing
OMB: 0920-1018
IC ID: 211022
OMB.report
HHS/CDC
OMB 0920-1018
ICR 201403-0920-017
IC 211022
( )
Documents and Forms
Document Name
Document Type
Follow-up Survey for RCT
Form
Follow-up Survey
Follow up Surveys_Screenshot.docx
Form
Att 3f Follow up-Intervention Comparison.docx
Follow-up Intervention
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Follow-up Survey for RCT
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
none
Follow-up Survey
Follow up Surveys_Screenshot.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,200
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
12,800
0
12,800
0
0
0
Annual IC Time Burden (Hours)
2,133
0
2,133
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Follow-up Intervention
Att 3f Follow up-Intervention Comparison.docx
03/27/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.