Information Collection

Formative Evaluation for Shigellosis Sexual Health Materials for Men who have Sex with Men

IC 226670 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Formative Evaluation for Shigellosis Sexual Health Materials for Men who have Sex with Men Form
Attachment 4_FG Moderator Guide.pdf Other-Moderator's Guide
Screener Attachment 2_Screener.docx Form
MSM Shigellosis Formative Research_Part B.docx Supporting Statement B IC Document
MSM Shigellosis Formative Research_Part A_050417.docx Supporting Statement A IC Document
GenICRequestTemplate_050417.docx Request for Approval IC Document
Attachment 3_Recruitment Script.docx Recruitment Script IC Document
Attachment 5_Informed Consent.docx Consent IC Document
5.Baltimore City Health Department.pdf Baltimore message IC Document
4.Seattle King County Web-based and Facebook Ads.docx Seattle Message IC Document
3.MN DH.pdf Minnesota message IC Document
2.SFDPH READING THIS MAY SAVE YOUR ASS - FINAL 03 13 13 (1).docx San Francisco message IC Document
1.CDC 2016.pdf CDC message IC Document
Attachment 6_IRB.pdf IRB determination IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Formative Evaluation for Shigellosis Sexual Health Materials for Men who have Sex with Men	Agency IC Tracking Number:	17ABT

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	none	Screener	Attachment 2_Screener.docx		Yes	No	Paper Only
Other-Moderator's Guide			Attachment 4_FG Moderator Guide.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 445	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	445	445
Annual IC Time Burden (Hours)	79	79
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement B	MSM Shigellosis Formative Research_Part B.docx	05/03/2017
Supporting Statement A	MSM Shigellosis Formative Research_Part A_050417.docx	05/08/2017
Request for Approval	GenICRequestTemplate_050417.docx	05/08/2017
Recruitment Script	Attachment 3_Recruitment Script.docx	05/08/2017
Consent	Attachment 5_Informed Consent.docx	05/08/2017
Baltimore message	5.Baltimore City Health Department.pdf	05/08/2017
Seattle Message	4.Seattle King County Web-based and Facebook Ads.docx	05/08/2017
Minnesota message	3.MN DH.pdf	05/08/2017
San Francisco message	2.SFDPH READING THIS MAY SAVE YOUR ASS - FINAL 03 13 13 (1).docx	05/08/2017
CDC message	1.CDC 2016.pdf	05/08/2017
IRB determination	Attachment 6_IRB.pdf	05/08/2017

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