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Behavioral Survey
[NCHHSTP] HIV Outpatient Study (HOPS)
OMB: 0920-1080
IC ID: 216377
OMB.report
HHS/CDC
OMB 0920-1080
ICR 202305-0920-009
IC 216377
( )
Documents and Forms
Document Name
Document Type
Behavioral Survey
Form and Instruction
Behavioral Survey (screenshots)
Att 3b_Behavioral Survey Screen Shots.pdf
Form and Instruction
Behavioral Survey (screenshots)
Att 3b_Behavioral Survey Screen Shots.pdf
Form and Instruction
Behavioral Survey
Att 3a_Behavioral Survey Instrument.docx
Form and Instruction
Behavioral Survey
Att 3a_Behavioral Survey Instrument.docx
Form and Instruction
Att 5_Behavioral Survey Instruction Card.docx
Behavioral Survey Instruction Card
IC Document
Att 5_Behavioral Survey Instruction Card.docx
Behavioral Survey Instruction Card
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Behavioral Survey
Agency IC Tracking Number:
0920-1080
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
n/a
Behavioral Survey (screenshots)
Att 3b_Behavioral Survey Screen Shots.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
n/a
Behavioral Survey
Att 3a_Behavioral Survey Instrument.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
09-20-0160 Records of Subjects in Health Promotion and Education Studies
FR Citation:
83 FR 6591
Number of Respondents:
2,700
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
2,700
0
0
0
0
2,700
Annual IC Time Burden (Hours)
315
0
0
0
0
315
Annual IC Cost Burden (Dollars)
8,100
0
0
0
0
8,100
Documents for IC
Title
Document
Date Uploaded
Behavioral Survey Instruction Card
Att 5_Behavioral Survey Instruction Card.docx
05/23/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.