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Screening Questionnaire
Exploring HIV Prevention Communication among Black Men Who Have Sex with Men in New York City: Project BROTHA
OMB: 0920-0872
IC ID: 194314
OMB.report
HHS/CDC
OMB 0920-0872
ICR 201008-0920-009
IC 194314
( )
Documents and Forms
Document Name
Document Type
Form No number
Screening Questionnaire
Form
No number Screening Questionnaire
Attachment 3a_Screening Questionnaires.07092010.docx
Form
3a Screening Questionaire 11_01-2010
Attachment 3a_Screening Questionnaires 11012010.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Screening Questionnaire
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
No number
Screening Questionnaire
Attachment 3a_Screening Questionnaires.07092010.docx
Yes
No
Fillable Fileable
Form
3a
Screening Questionaire 11_01-2010
Attachment 3a_Screening Questionnaires 11012010.docx
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
750
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
750
0
750
0
0
0
Annual IC Time Burden (Hours)
63
0
63
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
