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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
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
None
Pediatric HIV Confidential Case Report Form
Att_3(b) Pediatric Case Report Form 2023 v18.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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
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
3,363
0
3,186
0
0
177
Annual IC Time Burden (Hours)
1,962
0
1,903
0
0
59
Annual IC Cost Burden (Dollars)
0
0
-1,593
0
0
1,593
Documents for IC
Title
Document
Date Uploaded
Technical Guidance: Pediatric HIV Confidential Case Report Form
Att_4(b) PEDIATRIC HIV CASE REPORT FORM 2023 v2_PWID edit_clean.pdf
09/07/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.