Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Change Request-030812.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-04-19	Available
Attachment 4b Success Case Study Informed Consent Form 6.15.11.docx	Supplementary Document	Uploaded 2011-10-14	Available
Att 3j Follow-up interview log 082511.docx	Supplementary Document	Uploaded 2011-10-14	Available
Att 3j Follow-up interview log 082511.docx	Supplementary Document	Uploaded 2011-10-14	Available
Att 3i Participant Contact Log 082511.docx	Supplementary Document	Uploaded 2011-10-14	Available
Attachment 4a MyLife, MyStyle Informed Consent Form 6.15.11.docx	Supplementary Document	Uploaded 2011-10-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199775	Success Case Study Interview	Other-WORD	Modified
199774	6-Month Follow-up Questionnaire	Other-WORD	Modified
199773	3-Month Follow-up Questionnaire	Other-WORD	Modified
199772	Client Satisfaction Survey	Other-WORD	Modified
199771	Participant Contact Information Form	Other-WORD	Modified
199770	Baseline Questionnaire	Other-WORD	Modified
199769	Limited Locator Form	Other-WORD	Modified
199768	Outreach Recruitment Assessment	Other-WORD	Modified

ICR Details

OMB Control No: 0920-0913	ICR Reference No: 201204-0920-004
Status: Historical Active	Previous ICR Reference No: 201110-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/23/2012
	Date Received in OIRA: 04/23/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	01/31/2015	01/31/2015
Responses	3,984	0	3,984
Time Burden (Hours)	1,662	0	1,662
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request to make minor changes to some of the forms based on feedback.

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Authorizing Statute(s): US Code: 42 USC 301 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

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Participant Contact Information Form
Client Satisfaction Survey
Outreach Recruitment Assessment
Limited Locator Form
Baseline Questionnaire
3-Month Follow-up Questionnaire
6-Month Follow-up Questionnaire
Success Case Study Interview

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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	3,984	3,984	0	0	0	0
Annual Time Burden (Hours)	1,662	1,662	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $663,908

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? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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: 04/23/2012

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