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Post-Consultation Questionnaire
Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum
OMB: 0920-1361
IC ID: 249805
OMB.report
HHS/CDC
OMB 0920-1361
ICR 202109-0920-005
IC 249805
( )
Documents and Forms
Document Name
Document Type
Post-Consultation Questionnaire
Form and Instruction
Att 14a_Post-consultation questionnaire.docx
Other-WORD version of content to fac
Att 14a_Post-consultation questionnaire.docx
Other-WORD version of content to fac
Post-Consultation Questionnaire (screenshots)
Att 14b_Post-consultation questionnaire_screenshots.docx
Form and Instruction
Post-Consultation Questionnaire (screenshots)
Att 14b_Post-consultation questionnaire_screenshots.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Post-Consultation Questionnaire
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
Post-Consultation Questionnaire (screenshots)
Att 14b_Post-consultation questionnaire_screenshots.docx
Yes
Yes
Fillable Fileable
Other-WORD version of content to facilitate review
Att 14a_Post-consultation questionnaire.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
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:
3
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
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
12
0
12
0
0
0
Annual IC Time Burden (Hours)
2
0
2
0
0
0
Annual IC Cost Burden (Dollars)
198
0
198
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.