Aim 2a Cohort HIPAA Form (English & Spanish)

[NCHHSTP] Expanding PrEP in Communities of Color (EPICC)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1423 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-22GA Aim 2a Cohort HIPAA Form (English & Spanish) Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormEnglish Att_4h_Aim2aCohortHIPAAFormEnglish[1].docx Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormEnglish Att_4h_Aim2aCohortHIPAAFormEnglish[1].docx Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormSpanish Att_4h_Aim2aCohortHIPAAFormSpanish[1].docx Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormSpanish Att_4h_Aim2aCohortHIPAAFormSpanish[1].docx Form and Instruction

Information Collection (IC) Details

IC Title:	Aim 2a Cohort HIPAA Form (English & Spanish)	Agency IC Tracking Number:	0920-22GA

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	0920-22GA	Att 4h_Aim2aCohortHIPAAFormEnglish	Att_4h_Aim2aCohortHIPAAFormEnglish[1].docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-22GA	Att 4h_Aim2aCohortHIPAAFormSpanish	Att_4h_Aim2aCohortHIPAAFormSpanish[1].docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 134	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	134	134
Annual IC Time Burden (Hours)	11	11
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.