Quarterly Assessment

[NCHHSTP] Understanding HIV/STD Risk and Enhancing PrEP Implementation Messaging in a Diverse Community-Based Sample of Gay, Bisexual, and Other Men Who Have Sex with Men in a Transformational Era

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1421 can be found here:

Documents and Forms

Document Name Document Type
Quarterly Assessment Form and Instruction
Quarterly Assessment Att 4c_Quarterly assessment English.docx Form and Instruction
Quarterly Assessment Att 4c_Quarterly assessment English.docx Form and Instruction
Quarterly Assessment (Spanish) Att 4c_Quarterly assessment Spanish.docx Form and Instruction
Quarterly Assessment (Spanish) Att 4c_Quarterly assessment Spanish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Quarterly Assessment	Agency IC Tracking Number:	0920-23AQ

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	n/a	Quarterly Assessment	Att 4c_Quarterly assessment English.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Quarterly Assessment (Spanish)	Att 4c_Quarterly assessment Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 850	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,400	3,400
Annual IC Time Burden (Hours)	2,550	2,550
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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