Information Collection

Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)

IC 206753 under ICR 201301-0920-010 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Document Name Document Type
Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP) Form
Att 4d Screen shots (2) (3).docx Other-Screenshots
Eligibility Screener Att 1a Eligibility Screener.docx Form
Registration Att 1b Study Registration.docx Form
Baseline Survey Att 1c Baseline Survey.docx Form
Reporting of Self-Test Results Att 1d Reporting of Self-Test results.docx Form
Follow-up Survey Att 1e Follow up Survey.docx Form
Att 2a Consent Form.docx Consent IC Document
Att 3 IRB Emory.docx IRB IC Document
Att 4a Self-test referral sheet.docx Self-test Referral IC Document
Att 4b Banner Ad Example.docx Banner Ad Sample IC Document
Att 4c Communication Messages.docx Communication Messages IC Document
SS Part A.docx Supporting Statement A IC Document
SS Part B.docx Supporting Statement B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Evaluation of HIV Self-Testing Among MSM in High Prevalence Cities (eSTAMP)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Eligibility Screener	Att 1a Eligibility Screener.docx	Yes	Yes	Fillable Fileable
Form	none	Registration	Att 1b Study Registration.docx	Yes	Yes	Fillable Fileable
Form	none	Baseline Survey	Att 1c Baseline Survey.docx	Yes	Yes	Fillable Fileable
Form	none	Reporting of Self-Test Results	Att 1d Reporting of Self-Test results.docx	Yes	No	Fillable Fileable
Form	none	Follow-up Survey	Att 1e Follow up Survey.docx	Yes	Yes	Fillable Fileable
Other-Screenshots			Att 4d Screen shots (2) (3).docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	14,360	0	0	0	0	0
Annual IC Time Burden (Hours)	1,830	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Consent	Att 2a Consent Form.docx	04/24/2013
IRB	Att 3 IRB Emory.docx	04/24/2013
Self-test Referral	Att 4a Self-test referral sheet.docx	04/24/2013
Banner Ad Sample	Att 4b Banner Ad Example.docx	04/24/2013
Communication Messages	Att 4c Communication Messages.docx	04/24/2013
Supporting Statement A	SS Part A.docx	04/24/2013
Supporting Statement B	SS Part B.docx	04/24/2013

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