Information Collection

Evaluation of Rapid HIV Self-Testing: Qualitative and User Proficiency Assessments

IC 205155 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Attach1a_Eligibility_ScreenerElect[1].pdf Other-WORD
Attach1a_Eligibility_Screener[1].docx Other-WORD
Attach1b_Focus_Group_Guide[1].docx Other-WORD
Attach1c_In-Depth_Int_Guide[1].docx Other-WORD
Attach1e_Test_Result_Images[1].docx Other-WORD
Attach1d_User_Proficiency_Survey[1].docx Other-WORD
Attach1d_User_Proficiency_SurveyElect[1].pdf Other-WORD
Attach2a_Eligibility_Screener_Consent[1].docx Attach2a_Eligibility_Screener_Consent[1] IC Document
Attach2b_Focus_Group_Consent[1].docx Attach2b_Focus_Group_Consent[1] IC Document
Attach2d_Proficiency_Assessment_Consent[1].docx Attach2d_Proficiency_Assessment_Consent[1] IC Document
SS Part A.docx SS Part A IC Document
Screenshot for consent to participate.docx Screenshot for consent to participate IC Document
SS Part B.docx.docx SS Part B IC Document
eSTAMP Parts 1-2 Protocol IRB Clean 12.11.2012.docx eSTAMP Parts 1-2 Protocol IRB Clean 12 IC Document
Attach2c_In-Depth_Interview_Consent[1].docx Attach2c_In-Depth_Interview_Consent[1] IC Document
IRB_Approval_Letter_Part_1_and_2_09252012[1].pdf IRB_Approval_Letter_Part_1_and_2_09252012[1] IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Evaluation of Rapid HIV Self-Testing: Qualitative and User Proficiency Assessments	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD	Attach1a_Eligibility_ScreenerElect[1].pdf	Yes	Yes	Fillable Printable
Other-WORD	Attach1a_Eligibility_Screener[1].docx	Yes	Yes	Fillable Printable
Other-WORD	Attach1b_Focus_Group_Guide[1].docx	Yes	Yes	Fillable Printable
Other-WORD	Attach1c_In-Depth_Int_Guide[1].docx	Yes	Yes	Fillable Printable
Other-WORD	Attach1e_Test_Result_Images[1].docx	Yes	Yes	Fillable Printable
Other-WORD	Attach1d_User_Proficiency_Survey[1].docx	Yes	Yes	Fillable Printable
Other-WORD	Attach1d_User_Proficiency_SurveyElect[1].pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 430	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	430	0	0	0	0	0
Annual IC Time Burden (Hours)	121	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attach2a_Eligibility_Screener_Consent[1]	Attach2a_Eligibility_Screener_Consent[1].docx	12/12/2012
Attach2b_Focus_Group_Consent[1]	Attach2b_Focus_Group_Consent[1].docx	12/12/2012
Attach2d_Proficiency_Assessment_Consent[1]	Attach2d_Proficiency_Assessment_Consent[1].docx	12/12/2012
SS Part A	SS Part A.docx	12/13/2012
Screenshot for consent to participate	Screenshot for consent to participate.docx	12/13/2012
SS Part B	SS Part B.docx.docx	12/13/2012
eSTAMP Parts 1-2 Protocol IRB Clean 12	eSTAMP Parts 1-2 Protocol IRB Clean 12.11.2012.docx	12/13/2012
Attach2c_In-Depth_Interview_Consent[1]	Attach2c_In-Depth_Interview_Consent[1].docx	12/13/2012
IRB_Approval_Letter_Part_1_and_2_09252012[1]	IRB_Approval_Letter_Part_1_and_2_09252012[1].pdf	12/13/2012

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