Information Collection

Formative Tools for Addressing HIV Prevention Preferences among Adolescent MSM

IC 228661 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⚠️ Notice: This information collection may be referencing outdated material.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
Formative Tools for Addressing HIV Prevention Preferences among Adolescent MSM	Form
Survey screener Att 1a Screener AMSM Survey_.docx	Form
Survey - word Att 1c AMSM_Trans Survey.docx	Form
Survey AMSM - screenshots Att 1d ScreenShots - AMSM.docx	Form
Survey Trans - screenshots Att 1e ScreenShots - Trans.docx	Form
Att 1b AMSM Screener Diagram.pdf Survey Eligibility Flowchart	IC Document
Att 2 Consent & Assent Landing.docx Flyer	IC Document
Att 3a NORC IRB Approval Letter.pdf IRB approval	IC Document
Att 3b NORC IRB Approval Amendment 1.pdf IRB Amendment	IC Document
Att 3c NORC IRB Approval Amendment 2.pdf IRB amendment	IC Document
Att 3d NORC IRB Renewal Letter.pdf IRB Renewal	IC Document
Att 3e NORC IRB Approval Amendment 3.pdf IRB amendment	IC Document
Att 3g Sensitive Questions.docx Explanation for Sensitive Questions	IC Document
Att 4a Web Recruitment Ads.docx Web advertisement	IC Document
Att 4b Snapchat Recruitment Ads.docx Snapchat advertisement	IC Document
Att 4c Example Snapchat Video.mp4 Snapchat video ads	IC Document
Att 5 Data Security Plan.docx System Security Plan	IC Document
SSB.10.19.docx Supporting statement B	IC Document
SSA.10.19.docx Supporting Statement A	IC Document

IC Title:

Formative Tools for Addressing HIV Prevention Preferences among Adolescent MSM

Agency IC Tracking Number:

0920-0840-18AX

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	Survey screener	Att 1a Screener AMSM Survey_.docx	Yes	Yes	Fillable Fileable
Form	none	Survey - word	Att 1c AMSM_Trans Survey.docx	Yes	Yes	Fillable Fileable
Form	none	Survey AMSM - screenshots	Att 1d ScreenShots - AMSM.docx	Yes	Yes	Fillable Fileable
Form	none	Survey Trans - screenshots	Att 1e ScreenShots - Trans.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,875

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	7,875	7,875
Annual IC Time Burden (Hours)	1,677	1,677
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Eligibility Flowchart	Att 1b AMSM Screener Diagram.pdf	10/19/2017
Flyer	Att 2 Consent & Assent Landing.docx	10/19/2017
IRB approval	Att 3a NORC IRB Approval Letter.pdf	10/19/2017
IRB Amendment	Att 3b NORC IRB Approval Amendment 1.pdf	10/19/2017
IRB amendment	Att 3c NORC IRB Approval Amendment 2.pdf	10/19/2017
IRB Renewal	Att 3d NORC IRB Renewal Letter.pdf	10/19/2017
IRB amendment	Att 3e NORC IRB Approval Amendment 3.pdf	10/19/2017
Explanation for Sensitive Questions	Att 3g Sensitive Questions.docx	10/19/2017
Web advertisement	Att 4a Web Recruitment Ads.docx	10/19/2017
Snapchat advertisement	Att 4b Snapchat Recruitment Ads.docx	10/19/2017
Snapchat video ads	Att 4c Example Snapchat Video.mp4	10/19/2017
System Security Plan	Att 5 Data Security Plan.docx	10/19/2017
Supporting statement B	SSB.10.19.docx	10/19/2017
Supporting Statement A	SSA.10.19.docx	10/19/2017

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