Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
“Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients”
Referrals
This form identifies the submission of CBO-HPS referrals to CBO-OMP program staff.
Participant ID_______________________________________________________
List of CBO-HPS referrals given to the participant since last request: ______________________________________________________________________________________________________________________________________________________________________________________
Date grantee submitted the CBO-HPS Referrals to CBO-OMP program staff __/__/____.
Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and sending to PS16-1604 program staff. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (xxx-xxx).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |