Develop and Implement UCARE4LIFE Message Library

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Clinic Staff Pilot Study Qualitative Interviews - Provider Qualitative Interview Guide	Form and Instruction	New	Available
Form 1 Patient Pilot Study Qualitative Interviews - In Depth Interview Guide for Intervention Cases	Form and Instruction	New	Available
Form 1 Patient Pilot Study Surveys - Web based surveys	Form and Instruction	New	Available
Form 1 Patient Pilot Study Screener - Intervention Screener	Form and Instruction	New	Available
Form 1 Patient Focus Group Interview - Small Group Discussion Interview Guide	Form and Instruction	New	Available
Form 1 Patient Focus Group Screener - Small Group Discussion Screener	Form and Instruction	New	Available
supporting statement B.docx	Supporting Statement B	Uploaded 2013-08-30	Available
AppendixP_QuantitativeDataShells.docx	Supplementary Document	Uploaded 2013-08-30	Available
AppendixJ_3_IRBApprovalProvider.pdf	Supplementary Document	Uploaded 2013-08-30	Available
AppendixJ_2_IRBApprovalIntervention.pdf	Supplementary Document	Uploaded 2013-08-30	Available
AppendixJ_1_IRBApprovalNoticeSmallGroup.pdf	Supplementary Document	Uploaded 2013-08-30	Available
AppendixN_PocketCard.docx	Supplementary Document	Uploaded 2013-08-30	Available
5 AppendixM_HIPAAAuthorization.doc	Supplementary Document	Uploaded 2013-08-30	Available
5 AppendixL_2_ControlConsent.doc	Supplementary Document	Uploaded 2013-08-30	Available
5 AppendixL_1_CaseConsent.doc	Supplementary Document	Uploaded 2013-08-30	Available
3 AppendixD_SurveyRecruitmentFlyer.pub	Supplementary Document	Uploaded 2013-08-30	Available
AppendixK_2 Adult consent form for small group.docx	Supplementary Document	Uploaded 2013-08-30	Available
AppendixK_1 Adolescent assent form for small group.docx	Supplementary Document	Uploaded 2013-08-30	Available
2 AppendixR_SmallGroupDiscussionReminderEmail.docx	Supplementary Document	Uploaded 2013-08-30	Available
2 AppendixS_SampleTextMessageInventory.docx	Supplementary Document	Uploaded 2013-08-30	Available
1 AppendixQ_SmallGroupDiscussionElectronicAd.docx	Supplementary Document	Uploaded 2013-08-30	Available
AppendixA_SmallGroupDiscussionRecruitmentFlyer.pub	Supplementary Document	Uploaded 2013-08-30	Available
supporting statement A.docx	Supporting Statement A	Uploaded 2013-08-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208623	Clinic Staff Pilot Study Qualitative Interviews - Provider Qualitative Interview Guide	Form and Instruction	New
208622	Patient Pilot Study Qualitative Interviews - In Depth Interview Guide for Intervention Cases	Form and Instruction	New
208621	Patient Pilot Study Surveys - Web based surveys	Form and Instruction	New
208620	Patient Pilot Study Screener - Intervention Screener	Form and Instruction	New
208619	Patient Focus Group Interview - Small Group Discussion Interview Guide	Form and Instruction	New
208618	Patient Focus Group Screener - Small Group Discussion Screener	Form and Instruction	New

ICR Details

OMB Control No: 0915-0371	ICR Reference No: 201309-0915-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No: 20462
Title: Develop and Implement UCARE4LIFE Message Library
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/02/2013
	Date Received in OIRA: 09/12/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	24 Months From Approved
Responses	3,290	0	0
Time Burden (Hours)	1,969	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Easily implemented interventions are needed for HIV self-management. The information collected will be used to: 1) develop, test, and maintain a message library that addresses topics of HIV disease self-management and risk reduction and 2) develop, implement, conduct, and evaluate the text messaging. Respondents are racially and ethnically diverse HIV positive youth and young adults and health care providers.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 27406	05/10/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 54659	09/05/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Patient Focus Group Screener - Small Group Discussion Screener	1	Small Group Discussion Screener
Patient Focus Group Interview - Small Group Discussion Interview Guide	1	Small Group Discussion Guide
Patient Pilot Study Screener - Intervention Screener	1	Survey Screener
Patient Pilot Study Surveys - Web based surveys	1, 2	Pattient Baseline ,   Patient Follow-up
Patient Pilot Study Qualitative Interviews - In Depth Interview Guide for Intervention Cases	1	Patient Interview Guide
Clinic Staff Pilot Study Qualitative Interviews - Provider Qualitative Interview Guide	1	Clinical Interview Guide

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,290	0	0	3,290	0	0
Annual Time Burden (Hours)	1,969	0	0	1,969	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $604,022

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/12/2013

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