Pediatric HIV Confidential Case Report Form (with Perinatal HIV Exposure information)

[NCHHSTP] National HIV Surveillance System (NHSS)

Documents and Forms

Document Name Document Type
Form 0920-0573 Pediatric HIV Confidential Case Report Form (with Perinatal HIV Exposure information) Form and Instruction
Form 0920-0573 Pediatric HIV Confidential Case Report Form (with Perinatal HIV Exposure information) Form and Instruction
0920-0573 Pediatric HIV Confidential Case Report Form Att 3b_Pediatric HIV Confidential Case Report Form.pdf Form and Instruction
0920-0573 Pediatric HIV Confidential Case Report Form Att 3b_Pediatric HIV Confidential Case Report Form.pdf Form and Instruction
0920-0573 NHSS - Pediatric HIV Confidential Case Report Form (PCRF Att_3b Pediatric Case Report Form_clean.pdf Form and Instruction
0920-0573 NHSS - Pediatric HIV Confidential Case Report Form (PCRF Att_3b Pediatric Case Report Form_clean.pdf Form and Instruction
Att 4b_Tehnical Guidance_Ped HIV Conf Case Rpt Form.pdf Technical Guidance: Pediatric HIV Confidential Case Report Form IC Document
Att 4b_Tehnical Guidance_Ped HIV Conf Case Rpt Form.pdf Technical Guidance: Pediatric HIV Confidential Case Report Form IC Document

Information Collection (IC) Details

IC Title:	Pediatric HIV Confidential Case Report Form (with Perinatal HIV Exposure information)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	0920-0573	Pediatric HIV Confidential Case Report Form	Att 3b_Pediatric HIV Confidential Case Report Form.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0573	NHSS - Pediatric HIV Confidential Case Report Form (PCRF) 29AUG2025	Att_3b Pediatric Case Report Form_clean.pdf	N/A	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	3,363	3,363
Annual IC Time Burden (Hours)	1,962	1,962
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Technical Guidance: Pediatric HIV Confidential Case Report Form	Att 4b_Tehnical Guidance_Ped HIV Conf Case Rpt Form.pdf	12/19/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.