Information Collection

Project Engage: Engaging Gay "Community" Activism for Syphilis Prevention

IC 226015 under ICR 201511-0920-001 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Project Engage: Engaging Gay "Community" Activism for Syphilis Prevention	Form and Instruction
Eligibility Screener Att 5a-Eligibilty Screener.docx	Form and Instruction
Telephone Interview Guide Att 5b-Interview Guide.docx	Form and Instruction
Att 4-Consent Form.docx Consent Form	IC Document
Att 6-IRB Letter of Approval.pdf IRB Approval - MPHI	IC Document
Att 7-CDC Project Determination.pdf CDC Project Determination and Approval	IC Document
Att 3a-Recruitment Flyers.docx Recruitment Flyer	IC Document
Att 3b-Recruitment Scripts.docx Recruitment Script	IC Document
SSA Project Engage.docx Supporting Statement A	IC Document
SSB Project Engage.docx Supporting Statement B	IC Document

IC Title:

Project Engage: Engaging Gay "Community" Activism for Syphilis Prevention

Agency IC Tracking Number:

17YJ

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	NA	Eligibility Screener	Att 5a-Eligibilty Screener.docx	NA	No		Paper Only
Form and Instruction	NA	Telephone Interview Guide	Att 5b-Interview Guide.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form	Att 4-Consent Form.docx	03/10/2017
IRB Approval - MPHI	Att 6-IRB Letter of Approval.pdf	03/10/2017
CDC Project Determination and Approval	Att 7-CDC Project Determination.pdf	03/10/2017
Recruitment Flyer	Att 3a-Recruitment Flyers.docx	03/15/2017
Recruitment Script	Att 3b-Recruitment Scripts.docx	03/15/2017
Supporting Statement A	SSA Project Engage.docx	03/15/2017
Supporting Statement B	SSB Project Engage.docx	03/15/2017

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