Information Collection

Evaluating Act Against AIDS Social Marketing Campaign Phases Targeting Consumers--Extended Survey

IC 197629 under ICR 201105-0920-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Evaluating Act Against AIDS Social Marketing Campaign Phases Targeting Consumers--Extended Survey	Form and Instruction
1 Study Screener Attachment 6 Study Screener.doc	Form and Instruction
2 HIV/AIDS Survey Item Bank Attachment 3 Extended Survey dg.docx	Form
Attachment 4 Consent form.doc Attachment 4 Consent form	IC Document
Attachment 5 E-mail Notification.doc Attachment 5 E-mail Notification	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Study Screener	Attachment 6 Study Screener.doc		Yes	Yes	Fillable Fileable
Form	2	HIV/AIDS Survey Item Bank	Attachment 3 Extended Survey dg.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 4 Consent form	Attachment 4 Consent form.doc	04/28/2011
Attachment 5 E-mail Notification	Attachment 5 E-mail Notification.doc	04/28/2011

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