Screener for One-on-One Surveys

Promoting HIV Testing among Low Income Heterosexual Young Adult Black Men

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0869 can be found here:

Documents and Forms

Document Name Document Type
Form 3a Screener for One-on-One Surveys Form and Instruction
0920-09CJ_att3b_One-on-One Interview Guide OADS.06162010.docx Other-Interview Guide
0920-09CJ_att3b_One-on-One Interview Guide OADS 10062010.docx Other-Interview Guide att3b 100610
3a Screening Tool 0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx Form and Instruction
3c Screener for One-on-One Surveys 0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.OADS.docx Form and Instruction
3c 0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys. 0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.10062010.docx Form and Instruction
3a 0920-09CJ_att3a_Screener for One-on-One Interviews.10062 0920-09CJ_att3a_Screener for One-on-One Interviews.10062010-1.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Screener for One-on-One Surveys	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3a	Screening Tool	0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx	Yes	Yes	Fillable Fileable
Other-Interview Guide			0920-09CJ_att3b_One-on-One Interview Guide OADS.06162010.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3c	Screener for One-on-One Surveys	0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.OADS.docx	Yes	Yes	Fillable Fileable
Other-Interview Guide att3b 100610			0920-09CJ_att3b_One-on-One Interview Guide OADS 10062010.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3c	0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.10062010	0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.10062010.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3a	0920-09CJ_att3a_Screener for One-on-One Interviews.10062010-1	0920-09CJ_att3a_Screener for One-on-One Interviews.10062010-1.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	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	300	300
Annual IC Time Burden (Hours)	50	50
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.