HIV-negative Patients Seeking HIV Testing - ROI 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)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1357 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1357 HIV-negative Patients Seeking HIV Testing - ROI Form Form and Instruction
0920-1357 Patient Authorization to Disclose, Release and/or Obtain Att 14_GAIN ROI Form.pdf Form and Instruction
0920-1357 Patient Authorization to Disclose, Release and/or Obtain Att 14_GAIN ROI Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	HIV-negative Patients Seeking HIV Testing - ROI Form	Agency IC Tracking Number:	0920-1357-24AQ

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	0920-1357	Patient Authorization to Disclose, Release and/or Obtain Protected Health Information	Att 14_GAIN ROI Form.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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	Previously Approved
Annual Number of Responses for this IC	50	-115	165
Annual IC Time Burden (Hours)	8	-20	28
Annual IC Cost Burden (Dollars)	0	-526	526

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.