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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.