Information Collection

Study to Inform HIV Screening and PrEP Resources for Health Care Providers

IC 221086 under ICR 201407-0920-003 · OMB 0920-1027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1027 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Study to Inform HIV Screening and PrEP Resources for Health Care Providers	Form and Instruction
Sscreener Att A_Screener_CLEAN.docx	Form and Instruction
Consent and Interview Guide Att B_Consent Moderator Interview Tool_CLEAN.docx	Form and Instruction
Template-Screener.docx Request for Approval - screener	IC Document
Template-ProviderInterviews.docx Request for Approval - interview	IC Document
Screener Service Delivery Checklist.docx Checklist - screener	IC Document
Moderator Service Delivery Checklist.docx Checklist - interview	IC Document
Att C_JustificationTokenOfAppreciation.docx Justification for Incentive	IC Document
DI-Provider_Concept1.png Material for Testing - 1	IC Document
DI-Provider_Concept2.png Material for Testing - 2	IC Document
PrEP#2(Folder)v3.1_to CDC.DOCX Material for Testing - 3	IC Document
PrEP#3(easel-pad)v2.1_to CDC.DOCX Material for Testing - 4	IC Document
PrEP#4(AskYourMD-broch)v2.1_to CDC.DOCX Material for Testing - 5	IC Document
PrEP#5(AreYouReady-Broch)v2.1_to CDC.DOCX Material for Testing - 6	IC Document
PrEP#6&7(poster)v2.1_to CDC.DOCX Material for Testing - 7	IC Document
PrEP#10SexualHistory(mini-foldedcard)v2.1_to CDC.DOCX Material for Testing - 8	IC Document
PrEP#12(FAQs)v2.4_to CDC.DOCX Material for Testing - 9	IC Document
PrEP_Cover1.jpg Material for Testing - 10	IC Document
PrEP_Cover2.jpg Material for Testing - 11	IC Document

IC Title:

Study to Inform HIV Screening and PrEP Resources for Health Care Providers

Agency IC Tracking Number:

16ABK

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Consent and Interview Guide	Att B_Consent Moderator Interview Tool_CLEAN.docx		Yes	Yes	Fillable Fileable
Form and Instruction	none	Sscreener	Att A_Screener_CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 108

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	108	108
Annual IC Time Burden (Hours)	57	57
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval - screener	Template-Screener.docx	04/25/2016
Request for Approval - interview	Template-ProviderInterviews.docx	04/25/2016
Checklist - screener	Screener Service Delivery Checklist.docx	04/25/2016
Checklist - interview	Moderator Service Delivery Checklist.docx	04/25/2016
Justification for Incentive	Att C_JustificationTokenOfAppreciation.docx	04/25/2016
Material for Testing - 1	DI-Provider_Concept1.png	04/25/2016
Material for Testing - 2	DI-Provider_Concept2.png	04/25/2016
Material for Testing - 3	PrEP#2(Folder)v3.1_to CDC.DOCX	04/25/2016
Material for Testing - 4	PrEP#3(easel-pad)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 5	PrEP#4(AskYourMD-broch)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 6	PrEP#5(AreYouReady-Broch)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 7	PrEP#6&7(poster)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 8	PrEP#10SexualHistory(mini-foldedcard)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 9	PrEP#12(FAQs)v2.4_to CDC.DOCX	04/25/2016
Material for Testing - 10	PrEP_Cover1.jpg	04/25/2016
Material for Testing - 11	PrEP_Cover2.jpg	04/25/2016

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