Case Report Evaluations

[NCHHSTP] National HIV Surveillance System (NHSS)

Documents and Forms

Document Name Document Type
Case Report Evaluations Form and Instruction
Case Report Evaluations Form and Instruction
Adult HIV Confidential Case Report Form Att_3(a) Adult Case Report Form 2023 v17.pdf Form and Instruction
Adult HIV Confidential Case Report Form Att_3(a) Adult Case Report Form 2023 v17.pdf Form and Instruction
Pediatric HIV Confidential Case Report Form Att_3(b) Pediatric Case Report Form 2023 v18.pdf Form and Instruction
Pediatric HIV Confidential Case Report Form Att_3(b) Pediatric Case Report Form 2023 v18.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Case Report Evaluations	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	None	Adult HIV Confidential Case Report Form	Att_3(a) Adult Case Report Form 2023 v17.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	None	Pediatric HIV Confidential Case Report Form	Att_3(b) Pediatric Case Report Form 2023 v18.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC	FR Citation: 57 FR 62812

Number of Respondents: 59	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,015	5,015
Annual IC Time Burden (Hours)	1,672	1,672
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.