Information Collection

HIV Health Improvement Affinity Group Assessment

IC 227751 under ICR 201412-0920-011 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
HIV Health Improvement Affinity Group Assessment Form
Attachment D_State-Level Phone Interview Guide.docx Other-Interview Guide
HHIAG Assessment - word Attachment B_Web-based Assessment Instrument_Word Format.docx Form
HHIAG Assessment - web Attachment C_Web-based Assessment Instrumnet_Web Version.docx Form
HHIAG-EVAL-SSB.docx Supporting Statement B IC Document
Attachment A_Respondent List.docx List of Respondents IC Document
Attachment E_State Characteristics.docx Interview Selectees IC Document
Attachment F_Web-based Assessment Invitation Email.docx Assessment Invitation Email IC Document
Attachment G_Web-based Assessment Reminder Email.docx Assessment Reminder Email IC Document
Attachment H_State-level Phone Interview Invitation Email.docx Interview Invitation Email IC Document
Attachment I_State-level Phone Interview Invitation Phone Script.docx Interview Reminder Email IC Document
HHIAG-EVAL-SSA.docx Supporting Statement A IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIV Health Improvement Affinity Group Assessment	Agency IC Tracking Number:	0920-0879-17AXW

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	HHIAG Assessment - word	Attachment B_Web-based Assessment Instrument_Word Format.docx	Yes	Yes	Fillable Fileable
Form	none	HHIAG Assessment - web	Attachment C_Web-based Assessment Instrumnet_Web Version.docx	Yes	Yes	Fillable Fileable
Other-Interview Guide			Attachment D_State-Level Phone Interview Guide.docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 146	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	146	146
Annual IC Time Burden (Hours)	82	82
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement B	HHIAG-EVAL-SSB.docx	07/31/2017
List of Respondents	Attachment A_Respondent List.docx	07/31/2017
Interview Selectees	Attachment E_State Characteristics.docx	07/31/2017
Assessment Invitation Email	Attachment F_Web-based Assessment Invitation Email.docx	07/31/2017
Assessment Reminder Email	Attachment G_Web-based Assessment Reminder Email.docx	07/31/2017
Interview Invitation Email	Attachment H_State-level Phone Interview Invitation Email.docx	07/31/2017
Interview Reminder Email	Attachment I_State-level Phone Interview Invitation Phone Script.docx	07/31/2017
Supporting Statement A	HHIAG-EVAL-SSA.docx	07/31/2017

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