View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Study to Inform HIV Screening and PrEP Resources for Health Care Providers	Agency IC Tracking Number:	16ABK

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	none	Sscreener	Att A_Screener_CLEAN.docx		Yes	Yes	Fillable Fileable
Form and Instruction	none	Consent and Interview Guide	Att B_Consent Moderator Interview Tool_CLEAN.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 108	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

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	108	0	108	0	0	0
Annual IC Time Burden (Hours)	57	0	57	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval - screener	Template-Screener.docx	04/25/2016
Request for Approval - interview	Template-ProviderInterviews.docx	04/25/2016
Checklist - screener	Screener Service Delivery Checklist.docx	04/25/2016
Checklist - interview	Moderator Service Delivery Checklist.docx	04/25/2016
Justification for Incentive	Att C_JustificationTokenOfAppreciation.docx	04/25/2016
Material for Testing - 1	DI-Provider_Concept1.png	04/25/2016
Material for Testing - 2	DI-Provider_Concept2.png	04/25/2016
Material for Testing - 3	PrEP#2(Folder)v3.1_to CDC.DOCX	04/25/2016
Material for Testing - 4	PrEP#3(easel-pad)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 5	PrEP#4(AskYourMD-broch)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 6	PrEP#5(AreYouReady-Broch)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 7	PrEP#6&7(poster)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 8	PrEP#10SexualHistory(mini-foldedcard)v2.1_to CDC.DOCX	04/25/2016
Material for Testing - 9	PrEP#12(FAQs)v2.4_to CDC.DOCX	04/25/2016
Material for Testing - 10	PrEP_Cover1.jpg	04/25/2016
Material for Testing - 11	PrEP_Cover2.jpg	04/25/2016

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