Screening Form (UNCG)

HIV/AIDS Risk Reduction Interventions for African-American Heterosexual Men

Documents and Forms

Document Name Document Type
0920-10CM_Att3c_Screening Form (UNCG).docx Other-WORD
0920-10CM_Att4c_Consent Forms (UNCG).doc Consent Forms -- UNCG IC Document
0920-10CM_Att5c1_Invitation to Intervention (UNCG).doc Invitation IC Document
0920-10CM_Att5c2_Recruitment Flyer (UNCG).doc Recruitment Flyer IC Document
0920-10CM_Att5c3_Recruitment Script (UNCG).doc Recruitment Script IC Document
0920-10CM_Att5c4_Invitation to Email Screening (UNCG).doc Invitation to E-mail Screening IC Document
0920-10CM_Att5c5_Reminder Scripts (UNCG).doc Reminder Script IC Document
0920-10CM_Att5c6_Reminder Letter (UNCG).doc Reminder Letter IC Document
0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean.docx 0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean IC Document
0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean IC Document
0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean IC Document
0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean IC Document
0920-10CM_Att5c6_Reminder Letter UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c6_Reminder Letter UNCG 11[1].15.2010-clean IC Document

Information Collection (IC) Details

IC Title:	Screening Form (UNCG)	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
Other-WORD			0920-10CM_Att3c_Screening Form (UNCG).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	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	200	200
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Forms -- UNCG	0920-10CM_Att4c_Consent Forms (UNCG).doc	07/26/2010
Invitation	0920-10CM_Att5c1_Invitation to Intervention (UNCG).doc	07/29/2010
Recruitment Flyer	0920-10CM_Att5c2_Recruitment Flyer (UNCG).doc	07/29/2010
Recruitment Script	0920-10CM_Att5c3_Recruitment Script (UNCG).doc	07/29/2010
Invitation to E-mail Screening	0920-10CM_Att5c4_Invitation to Email Screening (UNCG).doc	07/29/2010
Reminder Script	0920-10CM_Att5c5_Reminder Scripts (UNCG).doc	07/29/2010
Reminder Letter	0920-10CM_Att5c6_Reminder Letter (UNCG).doc	07/29/2010
0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean	0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean	0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean	0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean	0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c6_Reminder Letter UNCG 11[1].15.2010-clean	0920-10CM_Att5c6_Reminder Letter UNCG 11[1].15.2010-clean.docx	11/22/2010

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