Information Collection

GYT: Get Yourself Tested

IC 205171 under ICR 201212-0920-006 · OMB 0920-0957.

Documents and Forms

Document Name Document Type
GYT: Get Yourself Tested Form
GYT: Get Yourself Tested Instrument Attach 6 SurveyInstrument GYT.docx Form
Attach 8 Screen Shots-Survey.docx Att 8 - Screenshots of Survey Instrument IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	GYT: Get Yourself Tested	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
Form	none	GYT: Get Yourself Tested Instrument	Attach 6 SurveyInstrument GYT.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 8 - Screenshots of Survey Instrument	Attach 8 Screen Shots-Survey.docx	12/17/2012

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