Formative Research and Tool Development

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Key Participant Information Sheet and Consent Form	Form and Instruction	New	Available
Interview Guide - Individual/Network	Form and Instruction	New	Available
Interview Guide - Community Leaders	Form and Instruction	New	Available
Interview Guide - Public Policy Stakeholders	Form and Instruction	New	Available
Demographic Screener	Form	New	Available
30 Day Post Survey	Form	New	Available
Enrollment Day Survey	Form	New	Available
Experimental Group Survey	Form	New	Available
Pilot Test HRRET POSTTEST Web-based Survey	Form and Instruction	New	Available
Pilot Test HRRET PRETEST Web-based Survey	Form and Instruction	New	Available
Pilot Study HRRET Screener Survey	Form and Instruction	New	Available
Review Material Risk Reduction Poster Option	Form	New	Available
CME Promotion Card	Form	New	Available
Review Material Adherence Brochure MD	Form	New	Available
Review Material Gardner Study Reprint	Form	New	Available
Review Material Retention Poster	Form	New	Available
Review Material Retention Brochure Patient	Form	New	Available
Review Material Patient Record Form	Form	New	Available
Review Material Retention Brochure MD	Form	New	Available
Review Material Patient Risk Reduction Brochure	Form	New	Available
Review Material Patient Action Plan	Form	New	Available
Review Material Risk Reduction MD Brochure	Form	New	Available
Review Material Adherence Wall Poster	Form	New	Available
Review Material Patient Baseline Screen	Form	New	Available
Review Material Brouchure and Folding Instructions	Form	New	Repair queued
Review Material Folder	Form	New	Available
Review Material-Envelope	Form	New	Available
Provider Screening Instrument	Form and Instruction	New	Available
Informed Consent Form	Form	New	Available
Paper and Pencil Survey	Form	New	Available
Provider Screening Instrument	Form and Instruction	New	Available
Review Material Patient Adherence Brochure	Form	New	Available
Discordant partner consent - Spanish	Form and Instruction	New	Available
Discordant partner consent - English	Form and Instruction	New	Available
PLWH consent - Spanish	Form and Instruction	New	Available
PLWH consent	Form and Instruction	New	Available
Provider info sheet and consent	Form and Instruction	New	Available
Discordant partners interview guide - Spanish	Form and Instruction	New	Available
Discordant partners interview guide - English	Form and Instruction	New	Available
PLWH interview guide - Spanish	Form and Instruction	New	Available
PLWH interview guide - English	Form and Instruction	New	Available
Discordant partners contact info - Spanish	Form	New	Available
Discordant partners contact info - English	Form	New	Available
Contact Information - Spanish	Form	New	Available
Contact Information - English	Form	New	Available
Discordant partners screener - Spanish	Form	New	Available
Discordant partners screeners - English	Form	New	Available
Study screener - Spanish	Form	New	Repair queued
Study screener - English	Form	New	Available
Provider interview guide	Form and Instruction	New	Available
Provider Demographic Questionnaire	Form	New	Available
Assessment - Spanish	Form	New	Available
Assessment - English	Form	New	Available
Messages and Outcomes - Spanish	Form	New	Available
Messages and Outcomes	Form	New	Available
Eligibility Screener -Spanish	Form	New	Available
Eligibility Screener - English	Form	New	Available
Consent	Form	New	Available
Screener	Form	New	Available
Formative Research Study	Form	New	Available
Form 0920-0840 Attachment 10_Landing Page and Banner Ad	Form and Instruction	New	Available
Form 0920-0840 Attachment 9_Enumeration Interview	Form and Instruction	New	Available
Form 0920-0840 Attachment 8_Focus Group Interview	Form and Instruction	New	Available
Form 0920-0840 Attachment 7_Key informant interview	Form and Instruction	New	Available
Form 0920-0840 Attachment 6_Behavioral Assessment	Form and Instruction	New	Available
Form 0920-0840 Attachment 5_Eligibility Screener	Form and Instruction	New	Available
Form 0920-0840 Attachment 4_Recruitment Debriefing	Form and Instruction	New	Available
Focus Group/Interview Guide - Spanish Version	Form and Instruction	New	Available
Focus Group/Interview Guide	Form and Instruction	New	Available
Eligibility Screener - Spanish Version	Form and Instruction	New	Available
Eligibility Screener	Form and Instruction	New	Available
2b - interview questionnaire - Spanish	Form	New	Available
2a - Interview questionnaire - English	Form	New	Available
Usability Assent	Form	New	Available
Usability Consent	Form	New	Available
Consent HC Providers	Form	New	Available
Assent PLWH & High Risk	Form	New	Available
Consent PLWH & High Risk Spanish	Form	New	Available
Consent PLWH & High Risk	Form	New	Available
End User Survey	Form	New	Available
Focus Group Assessment Spanish	Form	New	Available
Focus Group Assessment	Form	New	Available
HC Providers Guide	Form	New	Available
Form form High Risk Guide Spanish	Form	New	Available
High Risk Guide	Form	New	Available
PLWH Guide Spanish	Form	New	Available
PLWH Guide	Form	New	Available
Screener HIV Providers	Form	New	Available
Screener High Risk	Form	New	Available
Screener	Form	New	Available
DSTDP Assessment of STD Clinic Users	Form	New	Available
Follow-up Survey	Form	New	Available
Reporting of Self-Test Results	Form	New	Available
Baseline Survey	Form	New	Available
Registration	Form	New	Available
Eligibility Screener	Form	New	Available
Consent Form	Form	New	Available
Biomedical HIV Prevention Organizational Assessment Web-based Survey Screenshots	Form	New	Available
Motion Comic Focus Group Guide 1	Form	New	Available
Motion Comic Post Test Survey	Form	New	Available
Motion Comic Screener	Form	New	Available
Motion Comic Focus Group Guide 2	Form	New	Available
Motion Comic Pre Test Survey	Form	New	Repair queued
MMP Provider Survey Web-based Application Screenshots	Form	New	Available
MMP Provider Survey	Form	New	Available
Att 9 DHAP ConfidAssurance.doc	Supplementary Document	Uploaded 2013-01-31	Available
Att 7 Example Group Interview Guide.doc	Supplementary Document	Uploaded 2013-01-31	Repair queued
Att 6 Sample Screening Tool.doc	Supplementary Document	Uploaded 2013-01-31	Available
Att 5 Example Survey.doc	Supplementary Document	Uploaded 2013-01-31	Available
Att 4 Example Individual Interview Guide.doc	Supplementary Document	Uploaded 2013-01-31	Available
Att 3 Example Questions.doc	Supplementary Document	Uploaded 2013-01-31	Available
Att 2 - 60 day FRN.pdf	Supplementary Document	Uploaded 2013-01-31	Available
Att 1 AuthLegislation.doc	Supplementary Document	Uploaded 2013-01-31	Available
(ICROupdated) 0840 Generic 1-31-2013- SSA.doc	Supporting Statement A	Uploaded 2013-01-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217215	Local Effectiveness Assessment Project (LEAP): A Case Study of a Local Jurisdiction Providing HIV Services to MSM	Form and Instruction	New	Key Participant Information Sheet and Consent Form
217215	Local Effectiveness Assessment Project (LEAP): A Case Study of a Local Jurisdiction Providing HIV Services to MSM	Form and Instruction	New	Interview Guide - Individual/Network
217215	Local Effectiveness Assessment Project (LEAP): A Case Study of a Local Jurisdiction Providing HIV Services to MSM	Form and Instruction	New	Interview Guide - Community Leaders
217215	Local Effectiveness Assessment Project (LEAP): A Case Study of a Local Jurisdiction Providing HIV Services to MSM	Form and Instruction	New	Interview Guide - Public Policy Stakeholders
215770	Evaluating HIV/AIDS Focused Video Game for Young People	Form	New	Demographic Screener
215770	Evaluating HIV/AIDS Focused Video Game for Young People	Form	New	30 Day Post Survey
215770	Evaluating HIV/AIDS Focused Video Game for Young People	Form	New	Enrollment Day Survey
215770	Evaluating HIV/AIDS Focused Video Game for Young People	Form	New	Experimental Group Survey
214195	Pilot Test Study for the HIV Risk Reduction Educational Tool (HRRET)	Form and Instruction	New	Pilot Test HRRET POSTTEST Web-based Survey
214195	Pilot Test Study for the HIV Risk Reduction Educational Tool (HRRET)	Form and Instruction	New	Pilot Test HRRET PRETEST Web-based Survey
214195	Pilot Test Study for the HIV Risk Reduction Educational Tool (HRRET)	Form and Instruction	New	Pilot Study HRRET Screener Survey
214195	Pilot Test Study for the HIV Risk Reduction Educational Tool (HRRET)	Other-HRRET Website Content	New
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Risk Reduction Poster Option
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	CME Promotion Card
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Adherence Brochure MD
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Gardner Study Reprint
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Retention Poster
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Retention Brochure Patient
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Patient Record Form
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Retention Brochure MD
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Patient Risk Reduction Brochure
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Patient Action Plan
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Risk Reduction MD Brochure
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Adherence Wall Poster
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Patient Baseline Screen
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Brouchure and Folding Instructions
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Folder
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material-Envelope
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form and Instruction	New	Provider Screening Instrument
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Informed Consent Form
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Paper and Pencil Survey
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form and Instruction	New	Provider Screening Instrument
213098	Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form	New	Review Material Patient Adherence Brochure
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	Discordant partner consent - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	Discordant partner consent - English
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	PLWH consent - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	PLWH consent
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	Provider info sheet and consent
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	Discordant partners interview guide - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	Discordant partners interview guide - English
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	PLWH interview guide - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	PLWH interview guide - English
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Discordant partners contact info - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Discordant partners contact info - English
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Contact Information - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Contact Information - English
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Discordant partners screener - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Discordant partners screeners - English
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Study screener - Spanish
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Study screener - English
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form and Instruction	New	Provider interview guide
211515	Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	Form	New	Provider Demographic Questionnaire
211479	Testing Brief Messages for Black and Latino MSM	Form	New	Assessment - Spanish
211479	Testing Brief Messages for Black and Latino MSM	Form	New	Assessment - English
211479	Testing Brief Messages for Black and Latino MSM	Form	New	Messages and Outcomes - Spanish
211479	Testing Brief Messages for Black and Latino MSM	Form	New	Messages and Outcomes
211479	Testing Brief Messages for Black and Latino MSM	Form	New	Eligibility Screener -Spanish
211479	Testing Brief Messages for Black and Latino MSM	Form	New	Eligibility Screener - English
211298	Injection Behaviors Among Young Persons in Rural/Suburban Settings	Form	New	Consent
211298	Injection Behaviors Among Young Persons in Rural/Suburban Settings	Form	New	Screener
211298	Injection Behaviors Among Young Persons in Rural/Suburban Settings	Form	New	Formative Research Study
209930	Feasibility of HIV Behavioral Surveillance for Young MSM	Form and Instruction	New	Attachment 10_Landing Page and Banner Ad
209930	Feasibility of HIV Behavioral Surveillance for Young MSM	Form and Instruction	New	Attachment 9_Enumeration Interview
209930	Feasibility of HIV Behavioral Surveillance for Young MSM	Form and Instruction	New	Attachment 8_Focus Group Interview
209930	Feasibility of HIV Behavioral Surveillance for Young MSM	Form and Instruction	New	Attachment 7_Key informant interview
209930	Feasibility of HIV Behavioral Surveillance for Young MSM	Form and Instruction	New	Attachment 6_Behavioral Assessment
209930	Feasibility of HIV Behavioral Surveillance for Young MSM	Form and Instruction	New	Attachment 5_Eligibility Screener
209930	Feasibility of HIV Behavioral Surveillance for Young MSM	Form and Instruction	New	Attachment 4_Recruitment Debriefing
209289	Development of CDC's Act Against AIDS Social Marketing Campaigns Targeting Consumers	Other-WORD	New
208435	Testing Messages for Black and Latino MSM	Form and Instruction	New	Focus Group/Interview Guide - Spanish Version
208435	Testing Messages for Black and Latino MSM	Form and Instruction	New	Focus Group/Interview Guide
208435	Testing Messages for Black and Latino MSM	Form and Instruction	New	Eligibility Screener - Spanish Version
208435	Testing Messages for Black and Latino MSM	Form and Instruction	New	Eligibility Screener
207572	Testing Solutions for Sampling Challenges for MMP	Form	New	2b - interview questionnaire - Spanish
207572	Testing Solutions for Sampling Challenges for MMP	Form	New	2a - Interview questionnaire - English
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Usability Assent
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Usability Consent
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Consent HC Providers
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Assent PLWH & High Risk
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Consent PLWH & High Risk Spanish
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Consent PLWH & High Risk
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	End User Survey
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Focus Group Assessment Spanish
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Focus Group Assessment
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	HC Providers Guide
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	High Risk Guide Spanish
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	High Risk Guide
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	PLWH Guide Spanish
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	PLWH Guide
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Screener HIV Providers
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Screener High Risk
207103	Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	Form	New	Screener
206883	DSTP Assessment of STD Clinic Users	Form	New	DSTDP Assessment of STD Clinic Users
206883	DSTP Assessment of STD Clinic Users	Other-Consent	New
206753	Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	Other-Screenshots	New
206753	Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	Form	New	Follow-up Survey
206753	Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	Form	New	Reporting of Self-Test Results
206753	Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	Form	New	Baseline Survey
206753	Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	Form	New	Registration
206753	Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	Form	New	Eligibility Screener
206398	CBO Needs Assessment for Preparedness and Resources for Support of Biomedical HIV Prevention	Form	New	Consent Form
206398	CBO Needs Assessment for Preparedness and Resources for Support of Biomedical HIV Prevention	Form	New	Biomedical HIV Prevention Organizational Assessment Web-based Survey Screenshots
206398	CBO Needs Assessment for Preparedness and Resources for Support of Biomedical HIV Prevention	Other-Pre-test Telephone Interview Script	New
206246	Development of a Motion Comic for HIV/STI Prevention Among Young People Ages 15-24 Phase 2	Form	New	Motion Comic Focus Group Guide 1
206246	Development of a Motion Comic for HIV/STI Prevention Among Young People Ages 15-24 Phase 2	Form	New	Motion Comic Post Test Survey
206246	Development of a Motion Comic for HIV/STI Prevention Among Young People Ages 15-24 Phase 2	Form	New	Motion Comic Screener
206246	Development of a Motion Comic for HIV/STI Prevention Among Young People Ages 15-24 Phase 2	Form	New	Motion Comic Focus Group Guide 2
206246	Development of a Motion Comic for HIV/STI Prevention Among Young People Ages 15-24 Phase 2	Form	New	Motion Comic Pre Test Survey
205959	Formative Research and Tool Development: Survey of HIV Medical Care Providers to Guide the Medical Monitoring Project	Form	New	MMP Provider Survey Web-based Application Screenshots
205959	Formative Research and Tool Development: Survey of HIV Medical Care Providers to Guide the Medical Monitoring Project	Form	New	MMP Provider Survey

ICR Details

OMB Control No: 0920-0840	ICR Reference No: 201301-0920-010
Status: Historical Active	Previous ICR Reference No: 200910-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 18699
Title: Formative Research and Tool Development
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/01/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/31/2013
Terms of Clearance: Previous terms continue: OMB approves this umbrella generic, and has informed CDC that each individual study should be submitted into ROCIS an a ¿genIC¿ that includes the actual study instruments and a memo describing the specific study goal, the study design, any incentives to be used, and the sampling and analysis plans.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	36 Months From Approved	01/31/2013
Responses	121,800	0	121,800
Time Burden (Hours)	46,516	0	46,516
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Disease Control and Prevention (CDC) requests approval for a revised generic information collection that supports formative research in HIV/AIDS, sexually transmitted diseases, tuberculosis, and viral hepatitis.

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Authorizing Statute(s): US Code: 42 USC 241 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:
	77 FR 46094	08/02/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 71794	12/04/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

IC Title	Form No.	Form Name
CBO Needs Assessment for Preparedness and Resources for Support of Biomedical HIV Prevention	None, none	Biomedical HIV Prevention Organizational Assessment Web-based Survey Screenshots ,   Consent Form
DSTP Assessment of STD Clinic Users	none	DSTDP Assessment of STD Clinic Users
Development of CDC's Act Against AIDS Social Marketing Campaigns Targeting Consumers
Development of a Motion Comic for HIV/STI Prevention Among Young People Ages 15-24 Phase 2	none, none, none, none, none	Motion Comic Pre Test Survey ,   Motion Comic Focus Group Guide 2 ,   Motion Comic Screener ,   Motion Comic Post Test Survey ,   Motion Comic Focus Group Guide 1
Evaluating HIV/AIDS Focused Video Game for Young People	none, none, none, none	Enrollment Day Survey ,   Experimental Group Survey ,   30 Day Post Survey ,   Demographic Screener
Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	none, none, none, none, none	Eligibility Screener ,   Registration ,   Baseline Survey ,   Reporting of Self-Test Results ,   Follow-up Survey
Feasibility of HIV Behavioral Surveillance for Young MSM	0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840	Attachment 4_Recruitment Debriefing ,   Attachment 5_Eligibility Screener ,   Attachment 6_Behavioral Assessment ,   Attachment 7_Key informant interview ,   Attachment 8_Focus Group Interview ,   Attachment 9_Enumeration Interview ,   Attachment 10_Landing Page and Banner Ad
Formative Research and Tool Development: Survey of HIV Medical Care Providers to Guide the Medical Monitoring Project	none, none	MMP Provider Survey ,   MMP Provider Survey Web-based Application Screenshots
Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	None, None, None, None, None, None, None, None, None, None, None, None, None, None, None, None, None, None, None, None, None	Provider Screening Instrument ,   Paper and Pencil Survey ,   Informed Consent Form ,   Provider Screening Instrument ,   Review Material-Envelope ,   Review Material Folder ,   Review Material Brouchure and Folding Instructions ,   Review Material Patient Baseline Screen ,   Review Material Patient Adherence Brochure ,   Review Material Adherence Wall Poster ,   Review Material Risk Reduction MD Brochure ,   Review Material Patient Action Plan ,   Review Material Patient Risk Reduction Brochure ,   Review Material Retention Brochure MD ,   Review Material Patient Record Form ,   Review Material Retention Brochure Patient ,   Review Material Retention Poster ,   Review Material Gardner Study Reprint ,   Review Material Adherence Brochure MD ,   CME Promotion Card ,   Review Material Risk Reduction Poster Option
Informing the Development of Mobile Apps for HIV Prevention, Treatment & Care	none, none, none, none, none, none, form, none, none, none, none, none, none, none, none, none, none	Screener ,   Screener High Risk ,   Screener HIV Providers ,   PLWH Guide ,   PLWH Guide Spanish ,   High Risk Guide ,   High Risk Guide Spanish ,   HC Providers Guide ,   Focus Group Assessment ,   Focus Group Assessment Spanish ,   End User Survey ,   Consent PLWH & High Risk ,   Consent PLWH & High Risk Spanish ,   Assent PLWH & High Risk ,   Consent HC Providers ,   Usability Consent ,   Usability Assent
Injection Behaviors Among Young Persons in Rural/Suburban Settings	none, none, none	Formative Research Study ,   Screener ,   Consent
Local Effectiveness Assessment Project (LEAP): A Case Study of a Local Jurisdiction Providing HIV Services to MSM	None, None, None, None	Interview Guide - Public Policy Stakeholders ,   Interview Guide - Community Leaders ,   Interview Guide - Individual/Network ,   Key Participant Information Sheet and Consent Form
Pilot Test Study for the HIV Risk Reduction Educational Tool (HRRET)	None, None, None	Pilot Study HRRET Screener Survey ,   Pilot Test HRRET PRETEST Web-based Survey ,   Pilot Test HRRET POSTTEST Web-based Survey
Testing Brief Messages for Black and Latino MSM	none, none, none, none, none, none	Eligibility Screener - English ,   Eligibility Screener -Spanish ,   Messages and Outcomes ,   Messages and Outcomes - Spanish ,   Assessment - English ,   Assessment - Spanish
Testing Messages for Black and Latino MSM	none, none, none, none	Eligibility Screener ,   Eligibility Screener - Spanish Version ,   Focus Group/Interview Guide ,   Focus Group/Interview Guide - Spanish Version
Testing Solutions for Sampling Challenges for MMP	none, none	2a - Interview questionnaire - English ,   2b - interview questionnaire - Spanish
Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment	none, none, none, none, none, none, none, none, none, none, none, none, none, none, none, none, none, none, none	Provider Demographic Questionnaire ,   Provider interview guide ,   Study screener - English ,   Study screener - Spanish ,   Discordant partners screeners - English ,   Discordant partners screener - Spanish ,   Contact Information - English ,   Contact Information - Spanish ,   Discordant partners contact info - English ,   Discordant partners contact info - Spanish ,   PLWH interview guide - English ,   PLWH interview guide - Spanish ,   Discordant partners interview guide - English ,   Discordant partners interview guide - Spanish ,   Provider info sheet and consent ,   PLWH consent ,   PLWH consent - Spanish ,   Discordant partner consent - English ,   Discordant partner consent - Spanish

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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	121,800	121,800	0	0	0	0
Annual Time Burden (Hours)	46,516	46,516	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: $574,500

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 01/31/2013

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