Patient Baseline

[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⚠️ Notice: This information collection may be referencing outdated material.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
Patient Baseline Form and Instruction
Att 4c_Patient Baseline Assessment English.docx Att 4c_Patient Baseline Assessment_CLEAN.docx Form and Instruction
Att 4c_Patient Baseline Assessment English.docx Att 4c_Patient Baseline Assessment_CLEAN.docx Form and Instruction
Att 4c_Patient Baseline Assessment Spanish Att 4c_Patient Baseline Assessment Spanish_CLEAN.docx Form and Instruction
Att 4c_Patient Baseline Assessment Spanish Att 4c_Patient Baseline Assessment Spanish_CLEAN.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Baseline	Agency IC Tracking Number:	0920-1428-24DB

Is this a Common Form? Yes		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	n/a	Att 4c_Patient Baseline Assessment English.docx	Att 4c_Patient Baseline Assessment_CLEAN.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Att 4c_Patient Baseline Assessment Spanish	Att 4c_Patient Baseline Assessment Spanish_CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

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	Previously Approved
Annual Number of Responses for this IC	134	134
Annual IC Time Burden (Hours)	101	101
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.