Information Collection

Testing Brief Messages for Black and Latino MSM

IC 211479 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⚠️ Notice: This information collection may be referencing outdated material.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 Brief Messages for Black and Latino MSM	Form
Eligibility Screener - English Att 3 Eligib Screener.English.Webscreen.pdf	Form
Eligibility Screener -Spanish Att 5 Eligib Screener.Spanish.Webscreen.pdf	Form
Messages and Outcomes Att 11 Messages and Outcomes.Eng.Webscreen.pdf	Form
Messages and Outcomes - Spanish Att 13 Messages and Outcomes.Spanish.Webscreen.pdf	Form
Assessment - English Att 15 Assessment.English.WebScreen.pdf	Form
Assessment - Spanish Att 17 Assessment.Spanish.WebScreen.pdf	Form
SS Part A.docx Supporting Statement A	IC Document
SS Part B.docx Supporting Statement B	IC Document
Att 6 Info for Participants.English.doc Information Sheet - English	IC Document
att 7 Info for Participants.Eng.Webscreen.pdf Information Sheet - English screenshot	IC Document
Att 8 Info for Participants.Spanish.docx Information Sheet - Spanish	IC Document
Att 9 Info for Participants.Spanish.Webscreen.pdf Information Sheet - Spanish screenshot	IC Document
Att 2 Eligib Screener.English.docx Eligibility Screener - English word	IC Document
Att 4 Eligib Screener.Spanish.docx Eligibility Screener - Spanish word	IC Document
Att 10 Messages and Outcomes.English.docx Messages - English word	IC Document
Att 12 Messages and Outcomes.Spanish.docx Messages - Spanish word	IC Document
Att 14 Assessment.English.docx Assessment - English word	IC Document
Att 16 Assessment.Spanish.docx Assessment - Spanish word	IC Document
Att 18 Recruitment Materials.pdf Recruitment Materials	IC Document

IC Title:

Testing Brief 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	none	Eligibility Screener - English	Att 3 Eligib Screener.English.Webscreen.pdf	Yes	Yes	Fillable Fileable
Form	none	Eligibility Screener -Spanish	Att 5 Eligib Screener.Spanish.Webscreen.pdf	Yes	Yes	Fillable Fileable
Form	none	Messages and Outcomes	Att 11 Messages and Outcomes.Eng.Webscreen.pdf	Yes	Yes	Fillable Fileable
Form	none	Messages and Outcomes - Spanish	Att 13 Messages and Outcomes.Spanish.Webscreen.pdf	Yes	Yes	Fillable Fileable
Form	none	Assessment - English	Att 15 Assessment.English.WebScreen.pdf	Yes	Yes	Fillable Fileable
Form	none	Assessment - Spanish	Att 17 Assessment.Spanish.WebScreen.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,780

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	3,780	3,780
Annual IC Time Burden (Hours)	1,455	1,455
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	SS Part A.docx	05/01/2014
Supporting Statement B	SS Part B.docx	05/01/2014
Information Sheet - English	Att 6 Info for Participants.English.doc	05/01/2014
Information Sheet - English screenshot	att 7 Info for Participants.Eng.Webscreen.pdf	05/01/2014
Information Sheet - Spanish	Att 8 Info for Participants.Spanish.docx	05/01/2014
Information Sheet - Spanish screenshot	Att 9 Info for Participants.Spanish.Webscreen.pdf	05/01/2014
Eligibility Screener - English word	Att 2 Eligib Screener.English.docx	05/01/2014
Eligibility Screener - Spanish word	Att 4 Eligib Screener.Spanish.docx	05/01/2014
Messages - English word	Att 10 Messages and Outcomes.English.docx	05/01/2014
Messages - Spanish word	Att 12 Messages and Outcomes.Spanish.docx	05/01/2014
Assessment - English word	Att 14 Assessment.English.docx	05/01/2014
Assessment - Spanish word	Att 16 Assessment.Spanish.docx	05/01/2014
Recruitment Materials	Att 18 Recruitment Materials.pdf	05/01/2014

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