HIV-negative Patients Seeking HIV Testing and/or PrEP Services - 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)

Documents and Forms

Document Name Document Type
Form 0920-1357 HIV-negative Patients Seeking HIV Testing and/or PrEP Services - 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 and/or PrEP Services - ROI Form	Agency IC Tracking Number:	0920-1357-24AQ

Is this a Common Form? No		IC Status: Unchanged

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: 850	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	850	850
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.