Case Report Evaluations

[NCHHSTP] National HIV Surveillance System (NHSS)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0573 can be found here:

Documents and Forms

Document Name Document Type
Case Report Evaluations Form and Instruction
Adult HIV Confidential Case Report Form Att_3(a) Adult Case Report Form 2023 v17.pdf Form and Instruction
Adult HIV Confidential Case Report Form Att_3(a) Adult Case Report Form 2023 v17.pdf Form and Instruction
Pediatric HIV Confidential Case Report Form Att_3(b) Pediatric Case Report Form 2023 v18.pdf Form and Instruction
Pediatric HIV Confidential Case Report Form Att_3(b) Pediatric Case Report Form 2023 v18.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Case Report Evaluations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	None	Adult HIV Confidential Case Report Form	Att_3(a) Adult Case Report Form 2023 v17.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	None	Pediatric HIV Confidential Case Report Form	Att_3(b) Pediatric Case Report Form 2023 v18.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC	FR Citation: 57 FR 62812

Number of Respondents: 59	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,015	5,015
Annual IC Time Burden (Hours)	1,672	1,672
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.