Eligibility Screener

HIV prevention among Latina transgender women who have sex with men: Evaluation of a locally developed intervention

Documents and Forms

Document Name Document Type
Eligibility Screener Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English.docx Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English.docx Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish.doc Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish.doc Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English_30APR2019.pdf Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English_30APR2019.pdf Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish_30APR2019.pdf Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish_30APR2019.pdf Form and Instruction
0920-1266 ChiCAS Eligibility Screener - English JUN2021 Att 4a_ChiCAS Screener and Contact English.docx Form and Instruction
0920-1266 ChiCAS Eligibility Screener - English JUN2021 Att 4a_ChiCAS Screener and Contact English.docx Form and Instruction
0920-1266 ChiCAS Eligibility Screener - Spanish JUN2021 Att 4b_ChiCAS Screener and Contact Spanish.docx Form and Instruction
0920-1266 ChiCAS Eligibility Screener - Spanish JUN2021 Att 4b_ChiCAS Screener and Contact Spanish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form and Instruction	NA	ChiCAS Screener - English	Att 4a_ChiCAS Screener English.docx	NA	No	Paper Only
Form and Instruction	NA	ChiCAS Screener - Spanish	Att 4b_ChiCAS Screener Spanish.doc	NA	No	Paper Only
Form and Instruction	NA	ChiCAS Screener - English	Att 4a_ChiCAS Screener English_30APR2019.pdf	NA	No	Paper Only
Form and Instruction	NA	ChiCAS Screener - Spanish	Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	NA	No	Paper Only
Form and Instruction	0920-1266	ChiCAS Eligibility Screener - English JUN2021	Att 4a_ChiCAS Screener and Contact English.docx	NA	No	Paper Only
Form and Instruction	0920-1266	ChiCAS Eligibility Screener - Spanish JUN2021	Att 4b_ChiCAS Screener and Contact Spanish.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 140	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	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.