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Baseline Questionnaire
Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles
OMB: 0920-0913
IC ID: 199770
OMB.report
HHS/CDC
OMB 0920-0913
ICR 201411-0920-009
IC 199770
( )
Documents and Forms
Document Name
Document Type
Baseline Questionnaire
Form
Baseline Questionnaires
Att 3d_Baseline Questionnaire Clean.rtf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Baseline Questionnaire
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR 241
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
none
Baseline Questionnaires
Att 3d_Baseline Questionnaire Clean.rtf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
10
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
10
0
0
-518
0
528
Annual IC Time Burden (Hours)
10
0
0
-518
0
528
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.