Screener

Understanding Decisions and Barriers about PrEP Use and Uptake Among Men Who Have Sex With Men

Documents and Forms

Document Name Document Type
Screener Form and Instruction
PrEP Project Screener Att 3a Screener.docx Form and Instruction
Att 3g Screener_Beh Assessment Screen Caps.docx Eligibility Verification, Screener & Behavioral Assessment – Print Screens IC Document

Information Collection (IC) Details

IC Title:	Screener	Agency IC Tracking Number:

Is this a Common Form? No		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 and Instruction	NA	PrEP Project Screener	Att 3a Screener.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 600	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	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Eligibility Verification, Screener & Behavioral Assessment – Print Screens	Att 3g Screener_Beh Assessment Screen Caps.docx	09/24/2018

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