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ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
The Data to Care (D2C) Public Health Strategy: Successes, Challenges, and Lessons Learned in Identifying, Linking, and Reengaging Persons Diagnosed with HIV to Medical Care
Agency IC Tracking Number:
0920-1091-18QE
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
0920-1091
D2C Client Screener
Att 3a D2C Client Screener.docx
NA
No
Paper Only
Form and Instruction
0920-1091
D2C Client Interview Guide
Att 3b D2C Client Interview Guide - Revised 12MAR2018 - Clean.DOCX
NA
No
Paper Only
Form and Instruction
0920-1091
D2C Program Staff Interview Guide
Att 3c D2C Program Staff Interview Guide.DOCX
NA
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
210
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
210
0
210
0
0
0
Annual IC Time Burden (Hours)
100
0
100
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
D2C Recruitment Flyers
Att 1 D2C Recruitment Flyers.pdf
03/14/2018
Informed Consent Forms
Att 2 D2C Informed Consent Forms.docx
03/14/2018
CDC IRB Approval
Att 4a CDC IRB Approval 7072 New Approval Protocol_.pdf
03/14/2018
Emory IRB Approval
Att 4b Emory U IRB determination.pdf
03/14/2018
D2C Data Use Plan
Att 5 D2C Data Use Plan.doc
03/14/2018
Privacy Impact Assessment
Att 6 Privacy Impact Assessment.pdf
03/14/2018
Supporting Statement A
SSA_Revised 13MAR2018.docx
03/14/2018
Supporting Statement B
SSB.docx
03/14/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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