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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCHHSTP)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.