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HIV Risk Factor Questionnaire Blood donors Control Peripheral Sites
HIV Study in Blood Donors from Five Chinese Regions (NHLBI)
OMB: 0925-0596
IC ID: 213750
OMB.report
HHS/NIH
OMB 0925-0596
ICR 201411-0925-001
IC 213750
( )
Documents and Forms
Document Name
Document Type
Form 1
HIV Risk Factor Questionnaire Blood donors Control Peripheral Sites
Form and Instruction
1 HIV Risk Factor Questionnaire English
Attachment_1.1_HIV_Risk_Factor_Q_English_11_2014_V_8.0.docx
Form and Instruction
2 HIV Questionaire Informed Consent
Attachment_2_HIV_Questionaire_Informed Consent Form_11_2014_V_6.0.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
HIV Risk Factor Questionnaire Blood donors Control Peripheral Sites
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
1
HIV Risk Factor Questionnaire English
Attachment_1.1_HIV_Risk_Factor_Q_English_11_2014_V_8.0.docx
Yes
Yes
Fillable Fileable
Form
2
HIV Questionaire Informed Consent
Attachment_2_HIV_Questionaire_Informed Consent Form_11_2014_V_6.0.docx
Yes
Yes
Fillable Printable
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:
420
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
70 %
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
420
0
420
0
0
0
Annual IC Time Burden (Hours)
140
0
140
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.