Patient Baseline

[NCHHSTP] mChoice: Improving PrEP Uptake and Adherence among Minority MSM through Tailored Provider Training and Adherence Assistance in Two High Priority Settings

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.