Injection Behaviors Among Young Persons in Rural/Suburban Settings

Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material.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
Injection Behaviors Among Young Persons in Rural/Suburban Settings Form
Formative Research Study Att 2B_IDU Web-based Survey Screen Shots.pdf Form
Screener Att 4_Eligibility Screener_Process.docx Form
Consent Att 5_Verbal Consent Form.docx Form
Supporting Statement A.docx Supporting Statement A IC Document
Supporting Statement B.doc Supporting Statement B IC Document
Att 2A_IDU Web-based Survey.docx Survey - Word IC Document
Att 3_IRB Approval Certification.pdf IRB Approval IC Document
Att 6_Referral Coupon.docx Referral Coupons IC Document
Att 7_Certificate of Confidentiality.pdf Certificate of Confidentiality IC Document

Information Collection (IC) Details

IC Title:	Injection Behaviors Among Young Persons in Rural/Suburban Settings	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	Formative Research Study	Att 2B_IDU Web-based Survey Screen Shots.pdf	Yes	Yes	Fillable Fileable
Form	none	Screener	Att 4_Eligibility Screener_Process.docx	Yes	Yes	Fillable Fileable
Form	none	Consent	Att 5_Verbal Consent Form.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	394	394
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	Supporting Statement A.docx	04/16/2014
Supporting Statement B	Supporting Statement B.doc	04/16/2014
Survey - Word	Att 2A_IDU Web-based Survey.docx	04/16/2014
IRB Approval	Att 3_IRB Approval Certification.pdf	04/16/2014
Referral Coupons	Att 6_Referral Coupon.docx	04/16/2014
Certificate of Confidentiality	Att 7_Certificate of Confidentiality.pdf	04/16/2014

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