Information Collection

Evaluating HIV/AIDS Focused Video Game for Young People

IC 215770 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⚠️ Notice: This information collection may be referencing outdated material.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
Experimental Group Survey Evaluating HIV/AIDS Focused Video Game for Young People	Form
Enrollment Day Survey Evaluating HIV/AIDS Focused Video Game for Young People	Form
30 Day Post Survey Evaluating HIV/AIDS Focused Video Game for Young People	Form
Demographic Screener 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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.