Information Collection

Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs

IC 236556 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs	Form and Instruction
Focus Group Guide: Minority Men at Risk for Type 2 Diabe RMM Att 2 FocusGroupGuideAtRisk FINAL (7.1.2019).docx	Form and Instruction
Focus Group Guide: Minority Men Diagnosed with Type 2 Di RMM Att 3 FocusGroupGuideWithDiabetes FINAL (7.1.2019).docx	Form and Instruction
Screener RMM Att 4 FocusGroupScreener FINAL (7.1.2019).docx	Form and Instruction
Initial Screen Shot of the Web-based Survey (with OMB co RMM Att 10 Survey Intro Screenshot FINAL.docx	Form and Instruction
Survey (content) RMM Att 5 Survey Questionnaire Minority Male FINAL (7.1.2019).docx	Form and Instruction
RMM Att 1 PHSA Final.pdf Authorizing Legislation: Public Health Service Act	IC Document
RMM Att 6 IRB Approval FINAL.pdf IRB Approval	IC Document
RMM Att 7 Survey Consent FINAL.docx Survey Consent	IC Document
RMM Att 8 Participant Consent Form FINAL (7.1.2019).docx Focus Group Consent	IC Document
RMM Att 9 Example Stub & Banner Table Shell FINAL.xlsx Example Table Shells (how data will be analyzed)	IC Document
RMM SSA FINAL (7.2.2019).docx Supporting Statement Part A	IC Document
RMM SSB FINAL (7.1.2019).docx Supporting Statement Part B	IC Document

IC Title:

Reaching Minority Men Where They Are â Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs

Agency IC Tracking Number:

0920-19BHN

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	Focus Group Guide: Minority Men at Risk for Type 2 Diabetes	RMM Att 2 FocusGroupGuideAtRisk FINAL (7.1.2019).docx	No		Paper Only
Form and Instruction	n/a	Focus Group Guide: Minority Men Diagnosed with Type 2 Diabetes	RMM Att 3 FocusGroupGuideWithDiabetes FINAL (7.1.2019).docx	No		Paper Only
Form and Instruction	n/a	Screener	RMM Att 4 FocusGroupScreener FINAL (7.1.2019).docx	No		Paper Only
Form and Instruction	n/a	Initial Screen Shot of the Web-based Survey (with OMB control information)	RMM Att 10 Survey Intro Screenshot FINAL.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Survey (content)	RMM Att 5 Survey Questionnaire Minority Male FINAL (7.1.2019).docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,048

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,048	4,048
Annual IC Time Burden (Hours)	447	447
Annual IC Cost Burden (Dollars)	10,877	10,877

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Authorizing Legislation: Public Health Service Act	RMM Att 1 PHSA Final.pdf	07/01/2019
IRB Approval	RMM Att 6 IRB Approval FINAL.pdf	07/01/2019
Survey Consent	RMM Att 7 Survey Consent FINAL.docx	07/01/2019
Focus Group Consent	RMM Att 8 Participant Consent Form FINAL (7.1.2019).docx	07/01/2019
Example Table Shells (how data will be analyzed)	RMM Att 9 Example Stub & Banner Table Shell FINAL.xlsx	07/01/2019
Supporting Statement Part A	RMM SSA FINAL (7.2.2019).docx	07/02/2019
Supporting Statement Part B	RMM SSB FINAL (7.1.2019).docx	07/02/2019

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