Information Collection

Syringe Service Programs' (SSP) User Experiences

IC 233472 under ICR 202010-0920-010 · OMB 0920-1091.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Syringe Service Programs' (SSP) User Experiences	Form
Att 2d_SSP Client In-Depth Interview Guide.docx	Other-Interview Guide
Att 2e_SSP Staff and Stakeholder In-Depth Interview Guide.docx	Other-Interview Guide
Client Screener Att 2a_SSP Client Screening Form.docx	Form
Staff and Stakeholder Screener Att 2b_SSP Staff and Stakeholder Screening Form.docx	Form
Contact Information Form Att 2c_SSP Contact Form.docx	Form
SSA.docx Supporting Statement A	IC Document
SSB.docx Supporting Statement B	IC Document
Att 3a_SSP Client Informed Consent_CDC.docx Client Consent	IC Document
Att 3b_SSP Staff and Stakeholder Informed Consent_CDC.docx Staff Consent	IC Document
Att 4_IRB Approval.docx IRB Approval	IC Document
Att 5_Data Use Plan.doc Data Use Plan	IC Document
Att 1_Recruitment Materials.pdf Recruitment Materials	IC Document

IC Title:

Agency IC Tracking Number:

0920-1091-18BCZ

IC Status: Unchanged

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	none	Client Screener	Att 2a_SSP Client Screening Form.docx	Yes	Yes	Fillable Fileable
Form	none	Staff and Stakeholder Screener	Att 2b_SSP Staff and Stakeholder Screening Form.docx	Yes	Yes	Fillable Fileable
Form	none	Contact Information Form	Att 2c_SSP Contact Form.docx	No		Paper Only
Other-Interview Guide			Att 2d_SSP Client In-Depth Interview Guide.docx	Yes	Yes	Fillable Fileable
Other-Interview Guide			Att 2e_SSP Staff and Stakeholder In-Depth Interview Guide.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	SSA.docx	10/11/2018
Supporting Statement B	SSB.docx	10/11/2018
Client Consent	Att 3a_SSP Client Informed Consent_CDC.docx	10/11/2018
Staff Consent	Att 3b_SSP Staff and Stakeholder Informed Consent_CDC.docx	10/11/2018
IRB Approval	Att 4_IRB Approval.docx	10/11/2018
Data Use Plan	Att 5_Data Use Plan.doc	10/11/2018
Recruitment Materials	Att 1_Recruitment Materials.pdf	10/11/2018

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