Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Focus Group Questionnaire Category 2	Form	New	Available
Focus Group Eligibility Screener Category 2	Form	New	Available
Follow-up Interviews Category 2	Form	New	Repair queued
Baseline Interview Category 2	Form	New	Repair queued
Interview Eligibility Screener Category 2	Form	New	Available
Focus Group Questionnaire Category 1	Form	New	Available
Focus Group Eligibility Screener Category 1	Form and Instruction	New	Available
Follow-up Interviews Category 1	Form	New	Available
Baseline Interview Category 1	Form	New	Available
Interview Eligibility Screener Category 1	Form	New	Available
Att4f Staff Int Consent Cat 2.docx	Supplementary Document	Uploaded 2016-08-29	Available
Att4e Staff Int Consent Cat 1.docx	Supplementary Document	Uploaded 2016-08-29	Available
Att4d FG Consent Cat2.docx	Supplementary Document	Uploaded 2016-08-29	Available
Att4c FG Consent Cat 1.docx	Supplementary Document	Uploaded 2016-08-29	Available
Att4b PI Consent Cat 2.docx	Supplementary Document	Uploaded 2016-08-29	Available
Att4a PI Consent Cat1.docx	Supplementary Document	Uploaded 2016-08-29	Available
Att 2 60 Day FRN.pdf	Supplementary Document	Uploaded 2016-08-29	Available
Att 1 Legislative Authority.pdf	Supplementary Document	Uploaded 2016-08-29	Repair queued
SSB.docx	Supporting Statement B	Uploaded 2017-03-17	Available
SSA.docx	Supporting Statement A	Uploaded 2017-03-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223247	Staff Interview Category 2	Other-Interview Guide	New
223246	Focus Group Guide Category 2	Other-Focus Group Guide	New
223245	Focus Group Questionnaire Category 2	Form	New
223244	Focus Group Eligibility Screener Category 2	Form	New
223242	Follow-up Interviews Category 2	Form	New
223241	Baseline Interview Category 2	Form	New
223240	CBO-HPS Referrals Category 2	Instruction	New
223239	Medical Record Abstraction Category 2	Instruction	New
223238	Interview Eligibility Screener Category 2	Form	New
223237	Data Submission Categories 1 and 2	Instruction	New
223236	Staff Interview Category 1	Other-Interview Guide	New
223235	Focus Group Guide Category 1	Other-Focus Group Guide	New
223234	Focus Group Questionnaire Category 1	Form	New
223233	Focus Group Eligibility Screener Category 1	Form and Instruction	New
223232	Follow-up Interviews Category 1	Form	New
223231	Baseline Interview Category 1	Form	New
223230	CBO-HPS Referrals Category 1	Instruction	New
223229	Medical Record Abstraction Category 1	Instruction	New
223228	Interview Eligibility Screener Category 1	Form	New

ICR Details

OMB Control No: 0920-1172	ICR Reference No: 201608-0920-016
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AHI
Title: Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/17/2017
	Date Received in OIRA: 08/31/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved
Responses	4,378	0	0
Time Burden (Hours)	1,265	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal is to conduct enhanced outcome monitoring of HIV-positive clients and high-risk HIV negative clients at CDC-funded community-based organizations (CBOs) over time to increase understanding of HIV prevention and support services they receive, the outcomes of these services, and successes and challenges.

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Authorizing Statute(s): US Code: 42 USC 242 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 26795	05/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 59630	08/30/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 19

table that charts list of burden

IC Title	Form No.	Form Name
Staff Interview Category 1
Interview Eligibility Screener Category 1	none	Eligibility Screener
Medical Record Abstraction Category 1
CBO-HPS Referrals Category 1
Baseline Interview Category 1	none	Baseline Interview Category 1
Follow-up Interviews Category 1	none	Follow-up Interviews Category 1
Focus Group Eligibility Screener Category 1	none	Focus Group Eligibility Screener Category 1
Focus Group Guide Category 1
Data Submission Categories 1 and 2
Interview Eligibility Screener Category 2	none	Participant Eligibility Screener Category 2
Medical Record Abstraction Category 2
CBO-HPS Referrals Category 2
Baseline Interview Category 2	none	Baseine Interview Category 2
Follow-up Interviews Category 2	none	Follow-up Interviews Category 2
Focus Group Eligibility Screener Category 2	none	Focus Group Eligibility Screener Category 2
Focus Group Questionnaire Category 2	none	Foucs Group Questionnaire Category 2
Focus Group Questionnaire Category 1	none	Focus Group Eligibility Questionnaire Category 1
Focus Group Guide Category 2
Staff Interview Category 2

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,378	0	0	4,378	0	0
Annual Time Burden (Hours)	1,265	0	0	1,265	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR. Burden total is off by one hour due to rounding.

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Annual Cost to Federal Government: $2,134,519

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/31/2016

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