View Information Collection (IC)
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Assessing the acceptability and adoptability of HIV-1 PrEP technologies among African American women in the SE US
Agency IC Tracking Number:
0920-1091-19BSO
IC Status:
Unchanged
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
Screener
Att 3a_Study Screener.pdf
Yes
Yes
Fillable Fileable
Form
none
Contact information
Att 3b_Contact Information Form.docx
No
Paper Only
Other-Interview guide
Att 3c_In-depth Interview Guide.docx
Yes
No
Paper Only
Form
none
Demographic and behavioral questionnaire
Att 3d_Demographic and Behavioral Questionnaire.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
390
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
390
0
0
0
0
390
Annual IC Time Burden (Hours)
98
0
0
0
0
98
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
SS A.docx
10/10/2019
Supporting Statement B
SS B.docx
10/10/2019
Authorizing legislation
Att 1_Auth Legislation (1).pdf
10/10/2019
Authorizing legislation
Att 1_Auth Legislation.pdf
10/10/2019
Recruitment flyer
Att 2_Recruitment Flyer.pdf
10/10/2019
Consent
Att 4_Written Informed Consent Form.docx
10/10/2019
IRB Approval
Att 5_CDC IRB Approval.docx
10/10/2019
Data use plan
Att 6_Data Use Plan.doc
10/10/2019
PIA
Att 7_iQualR PIA_signed.pdf
10/10/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.