Information Collection

Assessment of QDS Data Coll. System and Dev't of HIV Prev. Decision Support Messages and Form. Research for the Web-based HIV Beh. Survey among MSM

IC 198250 under ICR 200910-0920-004 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessment of QDS Data Coll. System and Dev't of HIV Prev. Decision Support Messages and Form. Research for the Web-based HIV Beh. Survey among MSM	Form
Assessment - Survey Attachment 1_CLA_QDS Survey.docx	Form
Assessment - Screener Attachment 2_CLA_QDS Screener Form.docx	Form
Message Testing - interview screener Attach3 Screener_Qualitative Interview -SSG.doc	Form
Message Testing - Qualitative interview Attach1 Qualitative Interview-SSG .doc	Form
Message Testing - Survey screener Attach6 Screener_Web-based Survey -SSG.docx	Form
Message Testing - Web-based Survey Attach2 Web-based Survey-SSG .doc	Form
Web-based Survey - Web Survey Screener Attachment 1c_Eligibility Screener_Web-based Survey.docx	Form
Web-based Survey - Focus Group Screener Attachment 1a_Eligibility Screener_Focus Group.docx	Form
Web-based Survey - Focus Group Interview Attachment 1b_Focus Group Interview.docx	Form
Web-based Survey - Web Survey Questionnaire Attachment 1d_Web-based Survey.docx	Form
Supporting Statement - Part A.docx Assessment - Supporting Statement A	IC Document
Supporting Statement A-SSG.doc Message Testing - Supporting Statement A	IC Document
Attach4 Consent Form_Qualitative Interview -SSG.doc Message Testing - Interview Consent	IC Document
Attach5 Consent Form_Web-based Survey -SSG.doc Message Testing - Survey Consent	IC Document
Attach7 Web-based Survey Reminder Letter E-Mail Phone Scripts-SSG.doc Message Testing - Reminder letters	IC Document
Safer Sex Guide Attachment 8 Recruiting Flier (2).docx Message Testing - Recruitment Flyers	IC Document
Supporting Statement - Part A.docx Web-based Survey - Supporting Statement A	IC Document
Attachment 2a_Consent_in person focus group.docx Web-based Survey - In person Focus Group Consent	IC Document
Attachment 2b_Consent_online focus group.docx Web-based Survey - On line Focus Group Consent	IC Document
Attachment 2c_Consent_web-based survey.docx Web-based Survey - Web Survey Consent	IC Document
Attachment 3_Emory IRB Approval Letter.pdf Web-based Survey - IRB Approval	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Assessment of QDS Data Coll. System and Dev't of HIV Prev. Decision Support Messages and Form. Research for the Web-based HIV Beh. Survey among MSM

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Assessment - Survey	Attachment 1_CLA_QDS Survey.docx	Yes	Yes	Fillable Fileable
Form	none	Assessment - Screener	Attachment 2_CLA_QDS Screener Form.docx	Yes	Yes	Fillable Fileable
Form	none	Message Testing - interview screener	Attach3 Screener_Qualitative Interview -SSG.doc	No	No	Fillable Printable
Form	none	Message Testing - Qualitative interview	Attach1 Qualitative Interview-SSG .doc	Yes	Yes	Fillable Fileable
Form	none	Message Testing - Survey screener	Attach6 Screener_Web-based Survey -SSG.docx	Yes	Yes	Fillable Fileable
Form	none	Message Testing - Web-based Survey	Attach2 Web-based Survey-SSG .doc	Yes	Yes	Fillable Fileable
Form	none	Web-based Survey - Web Survey Screener	Attachment 1c_Eligibility Screener_Web-based Survey.docx	Yes	Yes	Fillable Fileable
Form	none	Web-based Survey - Focus Group Screener	Attachment 1a_Eligibility Screener_Focus Group.docx	Yes	Yes	Fillable Fileable
Form	none	Web-based Survey - Focus Group Interview	Attachment 1b_Focus Group Interview.docx	Yes	Yes	Fillable Fileable
Form	none	Web-based Survey - Web Survey Questionnaire	Attachment 1d_Web-based Survey.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,471

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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	17,471	0	0	0	0	0
Annual IC Time Burden (Hours)	2,497	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Assessment - Supporting Statement A	Supporting Statement - Part A.docx	06/20/2011
Message Testing - Supporting Statement A	Supporting Statement A-SSG.doc	06/20/2011
Message Testing - Interview Consent	Attach4 Consent Form_Qualitative Interview -SSG.doc	06/20/2011
Message Testing - Survey Consent	Attach5 Consent Form_Web-based Survey -SSG.doc	06/20/2011
Message Testing - Reminder letters	Attach7 Web-based Survey Reminder Letter E-Mail Phone Scripts-SSG.doc	06/20/2011
Message Testing - Recruitment Flyers	Safer Sex Guide Attachment 8 Recruiting Flier (2).docx	06/20/2011
Web-based Survey - Supporting Statement A	Supporting Statement - Part A.docx	06/20/2011
Web-based Survey - In person Focus Group Consent	Attachment 2a_Consent_in person focus group.docx	06/20/2011
Web-based Survey - On line Focus Group Consent	Attachment 2b_Consent_online focus group.docx	06/20/2011
Web-based Survey - Web Survey Consent	Attachment 2c_Consent_web-based survey.docx	06/20/2011
Web-based Survey - IRB Approval	Attachment 3_Emory IRB Approval Letter.pdf	06/20/2011

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