PositiveLinks Verbal Consent and Enrollment

Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum

Documents and Forms

Document Name Document Type
PositiveLinks Verbal Consent and Enrollment Form and Instruction
PositiveLinks Verbal Consent and Enrollment Att 12a_PositiveLinks verbal consent and enrollment.docx Form and Instruction
PositiveLinks Verbal Consent and Enrollment Att 12a_PositiveLinks verbal consent and enrollment.docx Form and Instruction

Information Collection (IC) Details

IC Title:	PositiveLinks Verbal Consent and Enrollment	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	n/a	PositiveLinks Verbal Consent and Enrollment	Att 12a_PositiveLinks verbal consent and enrollment.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems:(SORN) 09-20-0136	FR Citation: 57 FR 62812

Number of Respondents: 33	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	33	33
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	717	717

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.