Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Success Case Study Consent	Form	New	Available
RCT Consent	Form	New	Available
Success Case Study Interview	Form	Modified	Available
6 month Follow-up Questionnaire	Form	Modified	Available
3 month Follow-up Questionnaire	Form	Modified	Available
Client Satisfaction Survey	Form	Modified	Repair queued
Participant Contact Information	Form	Modified	Available
Baseline Questionnaires	Form	Modified	Available
Limited Locator Information	Form	Modified	Available
Outreach Recruitment Assessment	Form	Modified	Available
SS A Clean.docx	Supporting Statement A	Uploaded 2014-12-04	Available
Att 5b_Project Determination approval.pdf	Supplementary Document	Uploaded 2014-11-20	Available
Att 5a_MLMS IRB approval.pdf	Supplementary Document	Uploaded 2014-11-20	Available
Att 3k_Follow-up interview log.docx	Supplementary Document	Uploaded 2014-11-20	Available
Att 3j_Participant Contact Log.docx	Supplementary Document	Uploaded 2014-11-20	Available
Att 3a_Data Collection Flowchart.docx	Supplementary Document	Uploaded 2014-11-20	Available
Att 2a_Public Comment.docx	Supplementary Document	Uploaded 2014-11-20	Available
Att 2_60 Day FRN.pdf	Supplementary Document	Uploaded 2014-11-20	Available
Att 1_Public Health Service Act.docx	Supplementary Document	Uploaded 2014-11-20	Available
SS B Clean.docx	Supporting Statement B	Uploaded 2014-11-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213999	Success Case Study Consent	Form	New	Success Case Study Consent
213998	RCT Consent	Form	New	RCT Consent
199775	Success Case Study Interview	Form	Modified	Success Case Study Interview
199774	6-Month Follow-up Questionnaire	Form	Modified	6 month Follow-up Questionnaire
199773	3-Month Follow-up Questionnaire	Form	Modified	3 month Follow-up Questionnaire
199772	Client Satisfaction Survey	Form	Modified	Client Satisfaction Survey
199771	Participant Contact Information Form	Form	Modified	Participant Contact Information
199770	Baseline Questionnaire	Form	Modified	Baseline Questionnaires
199769	Limited Locator Form	Form	Modified	Limited Locator Information
199768	Outreach Recruitment Assessment	Form	Modified	Outreach Recruitment Assessment

ICR Details

OMB Control No: 0920-0913	ICR Reference No: 201411-0920-009
Status: Historical Active	Previous ICR Reference No: 201204-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/09/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/04/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	12 Months From Approved	01/31/2015
Responses	598	0	3,984
Time Burden (Hours)	459	0	1,662
Cost Burden (Dollars)	0	0	0

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Abstract: Extension request to complete enrollment of about 10 men to reach desired sample size and complete all follow-up surveys and interviews.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

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:
	79 FR 49519	08/21/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 70190	11/25/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
3-Month Follow-up Questionnaire	none	3 month Follow-up Questionnaire
6-Month Follow-up Questionnaire	none	6 month Follow-up Questionnaire
Baseline Questionnaire	none	Baseline Questionnaires
Client Satisfaction Survey	none	Client Satisfaction Survey
Limited Locator Form	none	Limited Locator Information
Outreach Recruitment Assessment	none	Outreach Recruitment Assessment
Participant Contact Information Form	none	Participant Contact Information
RCT Consent	none	RCT Consent
Success Case Study Consent	none	Success Case Study Consent
Success Case Study Interview	none	Success Case Study Interview

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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	598	3,984	0	0	-3,386	0
Annual Time Burden (Hours)	459	1,662	0	0	-1,203	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This extension request is to continue the study to reach the desired sample size. New ICs are just a different ICR presentation; burden hours are off by one hour due to rounding in ROCIS.

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Annual Cost to Federal Government: $663,908

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: 12/04/2014

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