Screening for patient interview

Midwest HIV Prevention and Pregnancy Planning Initiative (MHPPPI)

Documents and Forms

Document Name Document Type
0990-MHPPPI-Provider Survey_Introductory email.docx Other-survey
0990-MHPPPI-patient eligibility screener qual.docx Other-interview

Information Collection (IC) Details

IC Title:	Screening for patient interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-survey			0990-MHPPPI-Provider Survey_Introductory email.docx		No		Fillable Printable
Other-interview			0990-MHPPPI-patient eligibility screener qual.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	2	2
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.