Evaluating HIV/AIDS Focused Video Game for Young People

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⚠️ Notice: This information collection may be referencing outdated material.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
Evaluating HIV/AIDS Focused Video Game for Young People Form
Enrollment Day Survey Att_3b_ParticipantEnrollment Day Survey_Clean.docx Form
Experimental Group Survey Att_3c_Experimental Group Immediate Post Survey.docx Form
30 Day Post Survey Att_3d_Participant 30 Day Post Survey_Clean.docx Form
Demographic Screener Att_3a_ParticipantEligibilityForm_Clean.docx Form
SS_Part A (2)_Clean.docx SS Part A IC Document
SS_Part B_OMB_CLEAN.docx SS Part B IC Document
Att 1_Authorizing Legislation.pdf Legislation IC Document
Att_5a_ CDC 6701 IRB Approval.pdf IRB Approval IC Document
Att_2a_Parent Consent.docx Parental Consent IC Document
Att_2b_Adolescent Assent.docx Adolescent Consent IC Document
Att_2c_Adult Consent.docx Adult Consent IC Document
Att_4a_Study Recruitment Flyer.docx Recruitment Flyer IC Document
Att_6a_Game Screen Shots.docx Screen Shots IC Document

Information Collection (IC) Details

IC Title:	Evaluating HIV/AIDS Focused Video Game for Young People	Agency IC Tracking Number:	15VI

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR Publlic Health Service Act (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	none	Experimental Group Survey	Att_3c_Experimental Group Immediate Post Survey.docx	No	Paper Only
Form	none	Enrollment Day Survey	Att_3b_ParticipantEnrollment Day Survey_Clean.docx	No	Paper Only
Form	none	30 Day Post Survey	Att_3d_Participant 30 Day Post Survey_Clean.docx	No	Paper Only
Form	none	Demographic Screener	Att_3a_ParticipantEligibilityForm_Clean.docx	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	129	129
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SS Part A	SS_Part A (2)_Clean.docx	06/05/2015
SS Part B	SS_Part B_OMB_CLEAN.docx	06/05/2015
Legislation	Att 1_Authorizing Legislation.pdf	03/20/2015
IRB Approval	Att_5a_ CDC 6701 IRB Approval.pdf	03/20/2015
Parental Consent	Att_2a_Parent Consent.docx	03/20/2015
Adolescent Consent	Att_2b_Adolescent Assent.docx	03/20/2015
Adult Consent	Att_2c_Adult Consent.docx	03/20/2015
Recruitment Flyer	Att_4a_Study Recruitment Flyer.docx	03/25/2015
Screen Shots	Att_6a_Game Screen Shots.docx	06/05/2015

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