Eligibility Screener

[NCHHSTP] Understanding HIV/STD Risk and Enhancing PrEP Implementation Messaging in a Diverse Community-Based Sample of Gay, Bisexual, and Other Men Who Have Sex with Men in a Transformational Era

Documents and Forms

Document Name Document Type
Form 0920-24DF Eligibility Screener Form
0920-24DF Eligibility Screener English Att 4a_Eligibility Screener English_clean.docx Form
0920-24DF Eligibility Screener Spanish Att 4a_Eligibility Screener Spanish_clean.docx Form
0920-24DF Eligibility Screener English Att 4a_Eligibility Screener English_clean 6 4 2024.docx Form
0920-24DF Eligibility Screener Spanish Att 4a_Eligibility Screener Spanish_clean 6 4 2024.docx Form

Information Collection (IC) Details

IC Title:	Eligibility Screener	Agency IC Tracking Number:

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	0920-24DF	Eligibility Screener English	Att 4a_Eligibility Screener English_clean 6 4 2024.docx		Yes	Yes	Fillable Fileable
Form	0920-24DF	Eligibility Screener Spanish	Att 4a_Eligibility Screener Spanish_clean 6 4 2024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 850	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,700	1,700
Annual IC Time Burden (Hours)	142	142
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.