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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment
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
Provider Demographic Questionnaire
Att_2a_Provider Demographic Questionnaire.docx
No
Paper Only
Form and Instruction
none
Provider interview guide
Att_2b_Provider InDepth Interview Guide.docx
No
Paper Only
Form
none
Study screener - English
Att_2c_PLWH Study Screener-English.docx
No
Paper Only
Form
none
Study screener - Spanish
Att_2d_PLWH Study Screener-Spanish.docx
No
Paper Only
Form
none
Discordant partners screeners - English
Att_2e_HIV-discordant Partners Study Screener-English.docx
No
Paper Only
Form
none
Discordant partners screener - Spanish
Att_2f_HIV-discordant Partners Study Screener-Spanish.docx
No
Paper Only
Form
none
Contact Information - English
Att_2g_PLWH Contact Information Form English.docx
No
Paper Only
Form
none
Contact Information - Spanish
Att_2h_PLWH Contact Information Form Spanish.docx
No
Paper Only
Form
none
Discordant partners contact info - English
Att_2i_HIV Discordant Partners Contact Information Form English.docx
No
Paper Only
Form
none
Discordant partners contact info - Spanish
Att_2j_HIV Discordant Partners Contact Information Form Spanish.docx
No
Paper Only
Form and Instruction
none
PLWH interview guide - English
Att_2k_PLWH In-Depth Interview Guide-English.docx
No
Paper Only
Form and Instruction
none
PLWH interview guide - Spanish
Att_2l_PLWH In-Depth Interview Guide-Spanish.docx
No
Paper Only
Form and Instruction
none
Discordant partners interview guide - English
Att_2m_HIV-discordant Partners In-Depth Interview Guide-English.docx
No
Paper Only
Form and Instruction
none
Discordant partners interview guide - Spanish
Att_2n_HIV-discordant Partners In-Depth Interview Guide-Spanish.docx
No
Paper Only
Form and Instruction
none
Provider info sheet and consent
Att_3a_Provider Information Sheet and Consent Form.docx
No
Paper Only
Form and Instruction
none
PLWH consent
Att_3b_PLWH Consent Form- English.docx
No
Paper Only
Form and Instruction
none
PLWH consent - Spanish
Att_3c_PLWH Consent Form-Spanish.docx
No
Paper Only
Form and Instruction
none
Discordant partner consent - English
Att_3d_ HIV-discordant Partners Consent Form- English.docx
No
Paper Only
Form and Instruction
none
Discordant partner consent - Spanish
Att_3e_HIV-discordant Partners Consent Form- Spanish.docx
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:
590
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
590
0
590
0
0
0
Annual IC Time Burden (Hours)
167
0
167
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
05/06/2014
Supporting Statement B
Supporting Statement B.docx
05/06/2014
ABT IRB Approval
Att_4a_ABT IRB Approval Letter.pdf
05/06/2014
Emory IRB Approval
Att_4b_Emory University IRB Approval Letter.docx
05/06/2014
Provider recruitment script
Att_5a_Provider Recruitment Script.docx
05/06/2014
PLWH recruitment ads - English
Att_5b_PLWH Recruitment Advertisement English.docx
05/06/2014
PLWH recruitment ads - Spanish
Att_5c_PLWH Recruitment Advertisement Spanish.docx
05/06/2014
PLWH Recruitment flyers - English
Att_5d_PLWH RecruitFlyersEnglish.pdf
05/06/2014
PLWH recruitment flyers - Spanish
Att_5e_PLWH RecruitFlyersSpanish.pdf
05/06/2014
Spanish translation certification
Att_6a_Spanish Translation Certification.pdf
05/06/2014
ABT data security plan
Att_7a_ABT Data Security Plan.docx
05/06/2014
RSS data security plan
Att_7b_RSS Data Security Plan.docx
05/06/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.