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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.