View Information Collection (IC)
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ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Syringe Service Programs' (SSP) User Experiences
Agency IC Tracking Number:
0920-1091-18BCZ
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
Client Screener
Att 2a_SSP Client Screening Form.docx
Yes
Yes
Fillable Fileable
Form
none
Staff and Stakeholder Screener
Att 2b_SSP Staff and Stakeholder Screening Form.docx
Yes
Yes
Fillable Fileable
Form
none
Contact Information Form
Att 2c_SSP Contact Form.docx
No
Paper Only
Other-Interview Guide
Att 2d_SSP Client In-Depth Interview Guide.docx
Yes
Yes
Fillable Fileable
Other-Interview Guide
Att 2e_SSP Staff and Stakeholder In-Depth Interview Guide.docx
Yes
Yes
Fillable Fileable
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:
240
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
75 %
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
240
0
240
0
0
0
Annual IC Time Burden (Hours)
83
0
83
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
10/11/2018
Supporting Statement B
SSB.docx
10/11/2018
Client Consent
Att 3a_SSP Client Informed Consent_CDC.docx
10/11/2018
Staff Consent
Att 3b_SSP Staff and Stakeholder Informed Consent_CDC.docx
10/11/2018
IRB Approval
Att 4_IRB Approval.docx
10/11/2018
Data Use Plan
Att 5_Data Use Plan.doc
10/11/2018
Recruitment Materials
Att 1_Recruitment Materials.pdf
10/11/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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