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Monthly Study Report Form
[NCHHSTP] The GAIN (Greater Access and Impact with NAT) Study: Improving HIV Diagnosis, Linkage to Care, and Prevention Services with HIV Point-of-Care Nucleic Acid Tests (NATs)
OMB: 0920-1357
IC ID: 247946
OMB.report
HHS/CDC
OMB 0920-1357
ICR 202311-0920-002
IC 247946
( )
Documents and Forms
Document Name
Document Type
Monthly Study Report Form
Form and Instruction
Monthly Study Report Form
Att 5_GAIN monthly study report form.docx
Form and Instruction
Monthly Study Report Form
Att 5_GAIN monthly study report form.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Monthly Study Report Form
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
n/a
Monthly Study Report Form
Att 5_GAIN monthly study report form.docx
Yes
Yes
Fillable Fileable
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:
2
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
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
24
0
0
0
0
24
Annual IC Time Burden (Hours)
6
0
0
0
0
6
Annual IC Cost Burden (Dollars)
115
0
0
0
0
115
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.