Information Collection

Feasibility of HIV Behavioral Surveillance for Young MSM

IC 209930 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0840 Feasibility of HIV Behavioral Surveillance for Young MSM Form and Instruction
0920-0840 Attachment 4_Recruitment Debriefing Attachment 4_Recruitment Debriefing.doc Form and Instruction
0920-0840 Attachment 5_Eligibility Screener Attachment 5_Eligibility Screener.docx Form and Instruction
0920-0840 Attachment 6_Behavioral Assessment Attachment 6_Behavioral Assessment.docx Form and Instruction
0920-0840 Attachment 7_Key informant interview Attachment 7_Key informant interview.docx Form and Instruction
0920-0840 Attachment 8_Focus Group Interview Attachment 8_Focus Group Interview.docx Form and Instruction
0920-0840 Attachment 9_Enumeration Interview Attachment 9_Enumeration Interview.docx Form and Instruction
0920-0840 Attachment 10_Landing Page and Banner Ad Attachment 10_Landing Page and Banner Ad.docx Form and Instruction
Supporting Statement_Part A.docx Supporting Statement_Part A IC Document
Supporting Statement_Part B.docx Supporting Statement_Part B IC Document
Attachment 1_Sect 301 PHSA.doc Attachment 1_Sect 301 PHSA IC Document
Attachment 2_DCC authorization to operate.docx Attachment 2_DCC authorization to operate IC Document
Attachment 3_Recruiter Training Script.docx Attachment 3_Recruiter Training Script IC Document
Attachment 11_Assurance of Confidentiality.docx Attachment 11_Assurance of Confidentiality IC Document
Attachment 12_Agreement to abide by restrictions.doc Attachment 12_Agreement to abide by restrictions IC Document
Attachment 13_Assent and Consent Forms.docx Attachment 13_Assent and Consent Forms IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Feasibility of HIV Behavioral Surveillance for Young MSM	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 and Instruction	0920-0840	Attachment 4_Recruitment Debriefing	Attachment 4_Recruitment Debriefing.doc	Yes	Yes	Printable Only
Form and Instruction	0920-0840	Attachment 5_Eligibility Screener	Attachment 5_Eligibility Screener.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0840	Attachment 6_Behavioral Assessment	Attachment 6_Behavioral Assessment.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0840	Attachment 7_Key informant interview	Attachment 7_Key informant interview.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0840	Attachment 8_Focus Group Interview	Attachment 8_Focus Group Interview.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0840	Attachment 9_Enumeration Interview	Attachment 9_Enumeration Interview.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0840	Attachment 10_Landing Page and Banner Ad	Attachment 10_Landing Page and Banner Ad.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,446	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	5,446	0	0	0	0	0
Annual IC Time Burden (Hours)	1,715	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement_Part A	Supporting Statement_Part A.docx	12/30/2013
Supporting Statement_Part B	Supporting Statement_Part B.docx	12/30/2013
Attachment 1_Sect 301 PHSA	Attachment 1_Sect 301 PHSA.doc	12/30/2013
Attachment 2_DCC authorization to operate	Attachment 2_DCC authorization to operate.docx	12/30/2013
Attachment 3_Recruiter Training Script	Attachment 3_Recruiter Training Script.docx	12/30/2013
Attachment 11_Assurance of Confidentiality	Attachment 11_Assurance of Confidentiality.docx	12/30/2013
Attachment 12_Agreement to abide by restrictions	Attachment 12_Agreement to abide by restrictions.doc	12/30/2013
Attachment 13_Assent and Consent Forms	Attachment 13_Assent and Consent Forms.docx	12/30/2013

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