View Information Collection (IC)

View Information Collection (IC)

IC Title:	Adult	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	Adult Questionnaire	Adult Questionnaire	HIV Adult Questionnaire_120321.docx		Yes	Yes	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,685	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	16,820	0	16,820	0	0	0
Annual IC Time Burden (Hours)	12,340	0	12,340	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Overarching Guide	HIVOverarching Guide Cohort N.docx	07/16/2012
Adult Admin Guide	HIV Adult Admin Guide 120321_Cleaned.docx	07/16/2012

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