MARI - Empowering Latinas to Lash Out Against AIDS (ELLAS)

Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Document Name Document Type
MARI - Empowering Latinas to Lash Out Against AIDS (ELLAS) Form
Screener Att.1a_Screener 09 17 2010.docx Form
Group Interview Att.1c_Group Interviews.docx Form
Survey of Individual Att.1b_Survey of Individual (ACASI).docx Form
Health Care Provider Interview Att 1d_Individual Interview 09 17 2010.docx Form
SS Part A 10 04 2010.docx Supporting Statement A IC Document
Att.2a_ Informed Consents Latinas.08.11.2010.docx Consent for Pregnant Women and Focus Groups IC Document
Att 2b_ Informed Consents Health Care Providers 08112010.docx Consent for Health Care Providers IC Document
Att.3a_Local IRB approval.pdf IRB Approval IC Document
Att.2b_ Informed Consents Health Care Providers.12062010.docx Consent for Health Care Providers (Revised) IC Document

Information Collection (IC) Details

IC Title:	MARI - Empowering Latinas to Lash Out Against AIDS (ELLAS)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screener	Att.1a_Screener 09 17 2010.docx	Yes	No	Fillable Fileable
Form	none	Group Interview	Att.1c_Group Interviews.docx	No	No	Fillable Fileable
Form	none	Survey of Individual	Att.1b_Survey of Individual (ACASI).docx	Yes	Yes	Fillable Fileable
Form	none	Health Care Provider Interview	Att 1d_Individual Interview 09 17 2010.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 530	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	530	0	0	0	0	0
Annual IC Time Burden (Hours)	208	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	SS Part A 10 04 2010.docx	10/04/2010
Consent for Pregnant Women and Focus Groups	Att.2a_ Informed Consents Latinas.08.11.2010.docx	10/04/2010
Consent for Health Care Providers	Att 2b_ Informed Consents Health Care Providers 08112010.docx	10/04/2010
IRB Approval	Att.3a_Local IRB approval.pdf	10/04/2010
Consent for Health Care Providers (Revised)	Att.2b_ Informed Consents Health Care Providers.12062010.docx	12/06/2010

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