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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Project Engage: Engaging Gay "Community" Activism for Syphilis Prevention
Agency IC Tracking Number:
17YJ
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
Eligibility Screener
Att 5a-Eligibilty Screener.docx
NA
No
Paper Only
Form and Instruction
NA
Telephone Interview Guide
Att 5b-Interview Guide.docx
NA
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
100
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
100
0
100
0
0
0
Annual IC Time Burden (Hours)
45
0
45
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Consent Form
Att 4-Consent Form.docx
03/10/2017
IRB Approval - MPHI
Att 6-IRB Letter of Approval.pdf
03/10/2017
CDC Project Determination and Approval
Att 7-CDC Project Determination.pdf
03/10/2017
Recruitment Flyer
Att 3a-Recruitment Flyers.docx
03/15/2017
Recruitment Script
Att 3b-Recruitment Scripts.docx
03/15/2017
Supporting Statement A
SSA Project Engage.docx
03/15/2017
Supporting Statement B
SSB Project Engage.docx
03/15/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.