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Provider Baseline Survey
HIV Knowledge, Beliefs, Attitudes, and Practices of Providers in the Southeast
OMB: 0920-1160
IC ID: 222568
OMB.report
HHS/CDC
OMB 0920-1160
ICR 201607-0920-010
IC 222568
( )
Documents and Forms
Document Name
Document Type
Provider Baseline Survey
Form
Baseline survey
Att3a_Baseline Screener-Survey_clean.docx
Form
Baseline Screener and Survey Screenshots
Att9a_Screenshots_BaselineScreenerSurvey_clean.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Provider Baseline Survey
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
Baseline survey
Att3a_Baseline Screener-Survey_clean.docx
Yes
Yes
Fillable Fileable
Form
none
Baseline Screener and Survey Screenshots
Att9a_Screenshots_BaselineScreenerSurvey_clean.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,827
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
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
1,827
0
1,827
0
0
0
Annual IC Time Burden (Hours)
914
0
914
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.