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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Assessment of QDS Data Coll. System and Dev't of HIV Prev. Decision Support Messages and Form. Research for the Web-based HIV Beh. Survey among MSM
Agency IC Tracking Number:
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
none
Assessment - Survey
Attachment 1_CLA_QDS Survey.docx
Yes
Yes
Fillable Fileable
Form
none
Assessment - Screener
Attachment 2_CLA_QDS Screener Form.docx
Yes
Yes
Fillable Fileable
Form
none
Message Testing - interview screener
Attach3 Screener_Qualitative Interview -SSG.doc
No
No
Fillable Printable
Form
none
Message Testing - Qualitative interview
Attach1 Qualitative Interview-SSG .doc
Yes
Yes
Fillable Fileable
Form
none
Message Testing - Survey screener
Attach6 Screener_Web-based Survey -SSG.docx
Yes
Yes
Fillable Fileable
Form
none
Message Testing - Web-based Survey
Attach2 Web-based Survey-SSG .doc
Yes
Yes
Fillable Fileable
Form
none
Web-based Survey - Web Survey Screener
Attachment 1c_Eligibility Screener_Web-based Survey.docx
Yes
Yes
Fillable Fileable
Form
none
Web-based Survey - Focus Group Screener
Attachment 1a_Eligibility Screener_Focus Group.docx
Yes
Yes
Fillable Fileable
Form
none
Web-based Survey - Focus Group Interview
Attachment 1b_Focus Group Interview.docx
Yes
Yes
Fillable Fileable
Form
none
Web-based Survey - Web Survey Questionnaire
Attachment 1d_Web-based Survey.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
17,471
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
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
17,471
0
0
0
0
0
Annual IC Time Burden (Hours)
2,497
0
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Assessment - Supporting Statement A
Supporting Statement - Part A.docx
06/20/2011
Message Testing - Supporting Statement A
Supporting Statement A-SSG.doc
06/20/2011
Message Testing - Interview Consent
Attach4 Consent Form_Qualitative Interview -SSG.doc
06/20/2011
Message Testing - Survey Consent
Attach5 Consent Form_Web-based Survey -SSG.doc
06/20/2011
Message Testing - Reminder letters
Attach7 Web-based Survey Reminder Letter E-Mail Phone Scripts-SSG.doc
06/20/2011
Message Testing - Recruitment Flyers
Safer Sex Guide Attachment 8 Recruiting Flier (2).docx
06/20/2011
Web-based Survey - Supporting Statement A
Supporting Statement - Part A.docx
06/20/2011
Web-based Survey - In person Focus Group Consent
Attachment 2a_Consent_in person focus group.docx
06/20/2011
Web-based Survey - On line Focus Group Consent
Attachment 2b_Consent_online focus group.docx
06/20/2011
Web-based Survey - Web Survey Consent
Attachment 2c_Consent_web-based survey.docx
06/20/2011
Web-based Survey - IRB Approval
Attachment 3_Emory IRB Approval Letter.pdf
06/20/2011
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.