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Phase 1 Enrollment Survey
Identification of Behavioral and Clinical Predictors of Early HIV Infection (Project DETECT)
OMB: 0920-1100
IC ID: 218945
OMB.report
HHS/CDC
OMB 0920-1100
ICR 202112-0920-002
IC 218945
( )
Documents and Forms
Document Name
Document Type
Form 0920-1100
Phase 1 Enrollment Survey
Form and Instruction
Att 12a_Screenshots_REDCaP_Phase 1 Enrollment Survey.pdf
Other-Screenshot
Att 12a_Screenshots_REDCaP_Phase 1 Enrollment Survey.pdf
Other-Screenshot
0920-1100 Att 7a_Phase 1 Enrollment Survey (English)
Prt2 Wrksht_att 7_Phase 1 Enrollment Survey.pdf
Form and Instruction
0920-1100 Att 7a_Phase 1 Enrollment Survey (English)
Prt2 Wrksht_att 7_Phase 1 Enrollment Survey.pdf
Form and Instruction
0920-1100 Att 7b_Phase 1 Enrollment Survey (Spanish)
Att 7b_Phase 1 Enrollment Survey (Spanish).docx
Form and Instruction
0920-1100 Att 7b_Phase 1 Enrollment Survey (Spanish)
Att 7b_Phase 1 Enrollment Survey (Spanish).docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Phase 1 Enrollment Survey
Agency IC Tracking Number:
0920-1100
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?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
0920-1100
Att 7a_Phase 1 Enrollment Survey (English)
Prt2 Wrksht_att 7_Phase 1 Enrollment Survey.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
0920-1100
Att 7b_Phase 1 Enrollment Survey (Spanish)
Att 7b_Phase 1 Enrollment Survey (Spanish).docx
Yes
Yes
Fillable Fileable
Other-Screenshot
Att 12a_Screenshots_REDCaP_Phase 1 Enrollment Survey.pdf
Yes
Yes
Printable Only
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:
1,867
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
1,867
0
0
0
0
1,867
Annual IC Time Burden (Hours)
934
0
0
0
0
934
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.