Evaluation of TransLife Center (TLC): A Locally-Developed Combination Prevention Intervention for Transgender Women at High Risk of HIV Infection

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
TLC Interview	Form	Unchanged	Available
TLC Interview	Form	Unchanged	Available
TLC Follow Up Assessment	Form	Modified	Available
TLC Baseline Assessment	Form	Modified	Available
TLC Contact Information	Form	Unchanged	Available
TLC Eligibility Screener	Form	Unchanged	Available
SSB_23Aug2018.docx	Supporting Statement B	Uploaded 2018-09-28	Available
SSA_9Oct2018.docx	Supporting Statement A	Uploaded 2018-10-31	Available
Att 9_Certificate of Confidentiality.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 8 PIA 18CI Final.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 7_Data Use Plan.doc	Supplementary Document	Uploaded 2018-09-07	Available
Att 6c_UIC IRB Determination.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 6b_Chicago House IAA.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 6a_Lurie IRB Letter of Approval.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 5b_Consent to Interview.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 5a_Consent to Intervention.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 3_Recruitment Materials.doc	Supplementary Document	Uploaded 2018-09-07	Available
Att 2_60-Day FRN.pdf	Supplementary Document	Uploaded 2018-09-07	Available
Att 1_Auth Legislation.docx	Supplementary Document	Uploaded 2018-09-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
232941	Staff Interview	Form	Unchanged	TLC Interview
232939	Participant Interview	Form	Unchanged	TLC Interview
232936	Follow-up Assessment	Form	Modified	TLC Follow Up Assessment
232936	Follow-up Assessment	Other-Example Screen Shots of a Completed Follow-up Assessment	Modified
232934	Baseline Assessment	Form	Modified	TLC Baseline Assessment
232934	Baseline Assessment	Other-Example Screen Shots of a Completed Baseline Assessment	Modified
232931	Contact Information	Form	Unchanged	TLC Contact Information
232928	Eligibility Screening	Form	Unchanged	TLC Eligibility Screener

ICR Details

OMB Control No: 0920-1246	ICR Reference No: 201809-0920-009
Status: Historical Active	Previous ICR Reference No: 201807-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-18CI
Title: Evaluation of TransLife Center (TLC): A Locally-Developed Combination Prevention Intervention for Transgender Women at High Risk of HIV Infection
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: 10/31/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/28/2018
Terms of Clearance: Approved with the understanding that this is an exploratory study and incentive amounts, although more that typically offered, may be necessary to determine if a more rigorous study is possible.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved
Responses	465	0	0
Time Burden (Hours)	255	0	0
Cost Burden (Dollars)	6,207	0	0

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Abstract: The purpose of this data collection is to evaluate the Translife Center (TLC), which provides combination HIV prevention services to adult transgender women at high risk for HIV infection. Data will be used to compare pre-intervention levels of HIV risk to those at 4 and 8 months post-baseline. Data will be gathered by the cooperative agreement awardee, Chicago House & Social Service Agency, and partner organizations, the Ann & Robert H. Lurie Children’s Hospital of Chicago and the University of Illinois at Chicago. Information will be collected through interviewer and self-administered instruments. CDC is requesting a two-year approval.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

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:
	83 FR 4207	01/30/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 45451	09/07/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Baseline Assessment	n/a	TLC Baseline Assessment
Contact Information	n/a	TLC Contact Information
Eligibility Screening	n/a	TLC Eligibility Screener
Follow-up Assessment	n/a	TLC Follow Up Assessment
Participant Interview	n/a	TLC Interview
Staff Interview	n/a	TLC Interview

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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	465	0	0	465	0	0
Annual Time Burden (Hours)	255	0	0	255	0	0
Annual Cost Burden (Dollars)	6,207	0	0	6,207	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 information collection request.

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Annual Cost to Federal Government: $695,535

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 09/28/2018

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