Information Collection

Assessing the acceptability and adoptability of HIV-1 PrEP technologies among African American women in the SE US

IC 238087 under ICR 201808-0920-012 · OMB 0920-1091.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1091 can be found here:

Documents and Forms

Document Name Document Type
Assessing the acceptability and adoptability of HIV-1 PrEP technologies among African American women in the SE US Form
Att 3c_In-depth Interview Guide.docx Other-Interview guide
Screener Att 3a_Study Screener.pdf Form
Contact information Att 3b_Contact Information Form.docx Form
Demographic and behavioral questionnaire Att 3d_Demographic and Behavioral Questionnaire.pdf Form
SS A.docx Supporting Statement A IC Document
SS B.docx Supporting Statement B IC Document
Att 1_Auth Legislation (1).pdf Authorizing legislation IC Document
Att 1_Auth Legislation.pdf Authorizing legislation IC Document
Att 2_Recruitment Flyer.pdf Recruitment flyer IC Document
Att 4_Written Informed Consent Form.docx Consent IC Document
Att 5_CDC IRB Approval.docx IRB Approval IC Document
Att 6_Data Use Plan.doc Data use plan IC Document
Att 7_iQualR PIA_signed.pdf PIA IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Assessing the acceptability and adoptability of HIV-1 PrEP technologies among African American women in the SE US	Agency IC Tracking Number:	0920-1091-19BSO

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screener	Att 3a_Study Screener.pdf	Yes	Yes	Fillable Fileable
Form	none	Contact information	Att 3b_Contact Information Form.docx	No		Paper Only
Other-Interview guide			Att 3c_In-depth Interview Guide.docx	Yes	No	Paper Only
Form	none	Demographic and behavioral questionnaire	Att 3d_Demographic and Behavioral Questionnaire.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 390	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	390	390
Annual IC Time Burden (Hours)	98	98
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	SS A.docx	10/10/2019
Supporting Statement B	SS B.docx	10/10/2019
Authorizing legislation	Att 1_Auth Legislation (1).pdf	10/10/2019
Authorizing legislation	Att 1_Auth Legislation.pdf	10/10/2019
Recruitment flyer	Att 2_Recruitment Flyer.pdf	10/10/2019
Consent	Att 4_Written Informed Consent Form.docx	10/10/2019
IRB Approval	Att 5_CDC IRB Approval.docx	10/10/2019
Data use plan	Att 6_Data Use Plan.doc	10/10/2019
PIA	Att 7_iQualR PIA_signed.pdf	10/10/2019

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