Provider Locator Form

[NCHHSTP] mChoice: Improving PrEP Uptake and Adherence among Minority MSM through Tailored Provider Training and Adherence Assistance in Two High Priority Settings

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1428 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-22FZ Provider Locator Form Form and Instruction
0920-22FZ Att 4h_Provider Locator Form Att 4h_Provider Locator Form.docx Form and Instruction
0920-22FZ Att 4h_Provider Locator Form Att 4h_Provider Locator Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Provider Locator Form	Agency IC Tracking Number:	0920-22FZ

Is this a Common Form? Yes		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	0920-22FZ	Att 4h_Provider Locator Form	Att 4h_Provider Locator Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7	7
Annual IC Time Burden (Hours)	2	2
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.