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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Injection Behaviors Among Young Persons in Rural/Suburban Settings
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
Formative Research Study
Att 2B_IDU Web-based Survey Screen Shots.pdf
Yes
Yes
Fillable Fileable
Form
none
Screener
Att 4_Eligibility Screener_Process.docx
Yes
Yes
Fillable Fileable
Form
none
Consent
Att 5_Verbal Consent Form.docx
Yes
Yes
Fillable Fileable
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:
2,400
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
2,400
0
2,400
0
0
0
Annual IC Time Burden (Hours)
394
0
394
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
Supporting Statement A.docx
04/16/2014
Supporting Statement B
Supporting Statement B.doc
04/16/2014
Survey - Word
Att 2A_IDU Web-based Survey.docx
04/16/2014
IRB Approval
Att 3_IRB Approval Certification.pdf
04/16/2014
Referral Coupons
Att 6_Referral Coupon.docx
04/16/2014
Certificate of Confidentiality
Att 7_Certificate of Confidentiality.pdf
04/16/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.