Information Collection

Injection Behaviors Among Young Persons in Rural/Suburban Settings

IC 211298 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.