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
Client Screener Syringe Service Programs' (SSP) User Experiences	Form
Staff and Stakeholder Screener Syringe Service Programs' (SSP) User Experiences	Form
Contact Information Form 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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Yes	Yes	Fillable Fileable
Form	none	Yes	Yes	Fillable Fileable
Form	none	No		Paper Only
Other-Interview Guide		Yes	Yes	Fillable Fileable
Other-Interview Guide		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

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

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