Information Collection

Testing Messages for Black and Latino MSM

IC 208435 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Testing Messages for Black and Latino MSM	Form and Instruction
Eligibility Screener Attachment 1a Eligibility Screener.docx	Form and Instruction
Eligibility Screener - Spanish Version Attachment 1b ElgibilityScreener--Spanish.docx	Form and Instruction
Focus Group/Interview Guide Attachment 2a Focus Group_Interview Guide.docx	Form and Instruction
Focus Group/Interview Guide - Spanish Version Attachment 2b Focus Group_Interview Guide-Spanish.docx	Form and Instruction
SS Part A.docx Supporting Statement Part A	IC Document
SS Part B.docx Supporting Statement Part B	IC Document
Attachment 3a Information for participants.docx Information for Participants - English	IC Document
Attachment 3b Information for participants-Spanish.docx Information for Participants - Spanish	IC Document
Attachment 4a M4M Pilot RecruitmentFlyers for OMB.pdf Pilot Recruitment Flyers	IC Document
Attachment 4b M4M Pilot Recruitment Card for OMB.pdf Pilot Recruitment Cards	IC Document

IC Title:

Testing Messages for Black and Latino MSM

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Eligibility Screener	Attachment 1a Eligibility Screener.docx	Yes	No	Fillable Printable
Form and Instruction	none	Eligibility Screener - Spanish Version	Attachment 1b ElgibilityScreener--Spanish.docx	Yes	No	Fillable Printable
Form and Instruction	none	Focus Group/Interview Guide	Attachment 2a Focus Group_Interview Guide.docx	Yes	No	Fillable Printable
Form and Instruction	none	Focus Group/Interview Guide - Spanish Version	Attachment 2b Focus Group_Interview Guide-Spanish.docx	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 270

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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	270	0	0	0	0	0
Annual IC Time Burden (Hours)	150	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A	SS Part A.docx	08/29/2013
Supporting Statement Part B	SS Part B.docx	08/29/2013
Information for Participants - English	Attachment 3a Information for participants.docx	08/29/2013
Information for Participants - Spanish	Attachment 3b Information for participants-Spanish.docx	08/29/2013
Pilot Recruitment Flyers	Attachment 4a M4M Pilot RecruitmentFlyers for OMB.pdf	08/29/2013
Pilot Recruitment Cards	Attachment 4b M4M Pilot Recruitment Card for OMB.pdf	08/29/2013

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