Information Collection

Developing Tools to Engage Adolescent Men Who Have Sex with Men (AMSM)

IC 228556 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⚠️ Notice: This information collection may be referencing outdated material.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
Developing Tools to Engage Adolescent Men Who Have Sex with Men (AMSM)	Form and Instruction
Screener for In-person AMSM and Transgender Focus Groups Att 3a. Screener (In-Person Focus Groups).docx	Form and Instruction
Screener for Online AMSM and Transgender Focus Groups Att 3a. Screenshots of Screener (Online Focus Groups).docx	Form
AMSM Focus Group Guide Att 3b. AMSM Focus Group Guide.docx	Form and Instruction
Screenshots of AMSM Focus Group Guide Att 3b. Screenshots of AMSM Focus Group Guide.docx	Form
Transgender Youth Focus Group Guide Att 3c. Transgender Youth Focus Group Guide.docx	Form and Instruction
Screenshots of Transgender Youth Focus Group Guide Att 3c. Screenshots of Transgender Youth Focus Group Guide.docx	Form
SSA.docx Supporting Statement Part A	IC Document
SSB.docx Supporting Statement Part B	IC Document
Att 2--Federal Register Notice.pdf Federal Register Notice	IC Document
Att 4a. Informed Consent.docx Informed Consent for Participants 18 and Over	IC Document
Att 4a. 4b. Screenshots of Informed Assent Forms.docx Screenshots of Informed Assent or Consent	IC Document
Att 4c. Waiver Informed Consent.doc Waiver or Alteration of Informed Consent	IC Document
Att 4d. Waiver of Parental Permission.doc Waiver of Parental Permission	IC Document
Att 4e. Waiver HIPAA Authorization.doc Waiver of HIPAA Authorization	IC Document
Att 4f. Procedure for Reporting Child Abuse.doc Procedure for Reporting Suspected Child Abuse	IC Document
Att 5a. Focus Group Recruitment Ads.pptx Recruitment Advertisements	IC Document
Att 5b. Recruitment Language.docx Online Recruitment Ad Language	IC Document
Att 6a. The Fenway Institute IRB Approval Letter.pdf IRB Approval Letter	IC Document
Att 4b. Informed Assent.docx Informed Assent for Participants Under 18 Years of Age	IC Document
Att 6b. CDC HumanSubject Project Determination_2017.10.06.pdf CDC Research Project Determination Form	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Developing Tools to Engage Adolescent Men Who Have Sex with Men (AMSM)

Agency IC Tracking Number:

0920-17AZE

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 and Instruction	n/a	Screener for In-person AMSM and Transgender Focus Groups	Att 3a. Screener (In-Person Focus Groups).docx	No		Paper Only
Form	n/a	Screener for Online AMSM and Transgender Focus Groups	Att 3a. Screenshots of Screener (Online Focus Groups).docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	AMSM Focus Group Guide	Att 3b. AMSM Focus Group Guide.docx	No		Paper Only
Form	n/a	Screenshots of AMSM Focus Group Guide	Att 3b. Screenshots of AMSM Focus Group Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Transgender Youth Focus Group Guide	Att 3c. Transgender Youth Focus Group Guide.docx	No		Paper Only
Form	n/a	Screenshots of Transgender Youth Focus Group Guide	Att 3c. Screenshots of Transgender Youth Focus Group Guide.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems. HHS/CDC

FR Citation: 57 FR 62812

Number of Respondents: 72

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 67 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	72	72
Annual IC Time Burden (Hours)	198	198
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A	SSA.docx	10/04/2017
Supporting Statement Part B	SSB.docx	10/04/2017
Federal Register Notice	Att 2--Federal Register Notice.pdf	10/04/2017
Informed Consent for Participants 18 and Over	Att 4a. Informed Consent.docx	10/04/2017
Screenshots of Informed Assent or Consent	Att 4a. 4b. Screenshots of Informed Assent Forms.docx	10/04/2017
Waiver or Alteration of Informed Consent	Att 4c. Waiver Informed Consent.doc	10/04/2017
Waiver of Parental Permission	Att 4d. Waiver of Parental Permission.doc	10/04/2017
Waiver of HIPAA Authorization	Att 4e. Waiver HIPAA Authorization.doc	10/04/2017
Procedure for Reporting Suspected Child Abuse	Att 4f. Procedure for Reporting Child Abuse.doc	10/04/2017
Recruitment Advertisements	Att 5a. Focus Group Recruitment Ads.pptx	10/04/2017
Online Recruitment Ad Language	Att 5b. Recruitment Language.docx	10/04/2017
IRB Approval Letter	Att 6a. The Fenway Institute IRB Approval Letter.pdf	10/04/2017
Informed Assent for Participants Under 18 Years of Age	Att 4b. Informed Assent.docx	10/05/2017
CDC Research Project Determination Form	Att 6b. CDC HumanSubject Project Determination_2017.10.06.pdf	10/06/2017

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