Web-based HIV Behavioral Survey among Men who have Sex with Men

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Behavioral Assessment Survey (English)	Form	New	Available
Behavioral Assessment - Spanish version	Form	New	Available
Screener - Spanish version	Form	New	Available
Screener	Form	New	Available
Web-based project_Assurance Email.pdf	Supplementary Document	Uploaded 2012-03-13	Repair queued
Revised Campaign Message information.docx	Supplementary Document	Uploaded 2012-03-13	Available
Web based survey_Part B.docx	Supporting Statement B	Uploaded 2011-12-15	Available
Affordable Care HR3590 Citation.docx	Supplementary Document	Uploaded 2011-12-19	Available
Att 7 Model Consent Form.docx	Supplementary Document	Uploaded 2011-12-15	Available
Att 6 Assurance of confidentiality.pdf	Supplementary Document	Uploaded 2011-12-15	Available
Att 5b Public Comment_WHBS_final.docx	Supplementary Document	Uploaded 2011-12-15	Repair queued
Att 5a Public Comment.pdf	Supplementary Document	Uploaded 2011-12-15	Available
Att 4 60 day Federal Register Notice.pdf	Supplementary Document	Uploaded 2011-12-15	Available
Att 1c 308d Public Health Service Act.docx	Supplementary Document	Uploaded 2011-12-15	Available
Att 1b 306 Public Health Service Act.docx	Supplementary Document	Uploaded 2011-12-15	Available
Att 1a 301 Public Health Service Act.docx	Supplementary Document	Uploaded 2011-12-15	Available
Att 2c Screen Shots of Survey.pdf	Supplementary Document	Uploaded 2011-12-15	Available
Web based survey_Part A.docx	Supporting Statement A	Uploaded 2011-12-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
200523	Behavioral Assessment	Form	New	Behavioral Assessment Survey (English)
200523	Behavioral Assessment	Form	New	Behavioral Assessment - Spanish version
200522	Eligibility Screener	Form	New	Screener - Spanish version
200522	Eligibility Screener	Form	New	Screener

ICR Details

OMB Control No: 0920-0928	ICR Reference No: 201112-0920-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Web-based HIV Behavioral Survey among Men who have Sex with Men
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/30/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/19/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2015	36 Months From Approved
Responses	479,090	0	0
Time Burden (Hours)	44,819	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC has received funding from the Affordable Care Act's Prevention and Public Health Fund to conduct an annual, national, web-based behavioral suvey to monitor HIV risk behavior and exposure to prevention services among internet-using MSM. Data will be collected in 56 jurisdictions and 21 MSAs with the highest AIDS prevalence in the US. The data will enhance CDC's ability to monitor national trends in HIV and direct HIV prevention programs and policies.

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Authorizing Statute(s): US Code: 42 USC 301,306 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 125	06/29/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 78262	12/16/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Behavioral Assessment	none, none	Behavioral Assessment - Spanish version ,   Behavioral Assessment Survey (English)
Eligibility Screener	none, none	Screener ,   Screener - Spanish version

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	479,090	0	0	479,090	0	0
Annual Time Burden (Hours)	44,819	0	0	44,819	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR; it is ACA funded.

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Annual Cost to Federal Government: $1,055,487

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/19/2011

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