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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Barriers and Facilitators to HIV Prevention, Care and Treatment among Trasngender Women in Atlanta, Philadelphia and Washington, DC
Agency IC Tracking Number:
17KT
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
Eligibility Screener
Att 3a Eligibility Screener Transg Women.docx
No
Paper Only
Form
none
Demographic Questionnaire - Transgender Women
Att 3b DemoQuestionnaire Trans Women.docx
Yes
No
Paper Only
Form
none
Demographic Questionnaire - Healthcare Providers
Att 3c DemoQuestonnaire Healthcare Providers.docx
No
Paper Only
Form
none
INterview Guide HIV- Transgender Women
Att 3d Interview Guide HIV Negative Transgender Women.docx
No
Paper Only
Form
none
Interview Guide - HIV+ Transgender Women
Att 3e Interview Guide HIV Positive TransWomen.docx
No
Paper Only
Form
none
Interview Guide Healthcare Providers
Att 3f Interview Guide Healthcare Providers.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
180
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
180
0
180
0
0
0
Annual IC Time Burden (Hours)
61
0
61
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
SSA.docx
01/12/2017
Supporting Statement B
SSB.docx
01/12/2017
Recruitment Materials
Att 1 Recruitment Materials.docx
01/12/2017
Consent Forms
Att 2 Consent Forms.docx
01/12/2017
IRB Approval
Att 4 Abt IRB 0853 Transgender Full Approval.pdf
01/12/2017
Certificate of Confidentiality
Attachment 5 CoC Barriers and Facilitators to HIV Prevention, Care, and Treatment amo....pdf
01/12/2017
Research Determination
Tqual Project-Determination-and-Approval-Form _JD_Approval-9-7-16.pdf
01/12/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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