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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Testing Brief Messages for Black and Latino MSM
Agency IC Tracking Number:
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
Eligibility Screener - English
Att 3 Eligib Screener.English.Webscreen.pdf
Yes
Yes
Fillable Fileable
Form
none
Eligibility Screener -Spanish
Att 5 Eligib Screener.Spanish.Webscreen.pdf
Yes
Yes
Fillable Fileable
Form
none
Messages and Outcomes
Att 11 Messages and Outcomes.Eng.Webscreen.pdf
Yes
Yes
Fillable Fileable
Form
none
Messages and Outcomes - Spanish
Att 13 Messages and Outcomes.Spanish.Webscreen.pdf
Yes
Yes
Fillable Fileable
Form
none
Assessment - English
Att 15 Assessment.English.WebScreen.pdf
Yes
Yes
Fillable Fileable
Form
none
Assessment - Spanish
Att 17 Assessment.Spanish.WebScreen.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,780
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
3,780
0
3,780
0
0
0
Annual IC Time Burden (Hours)
1,455
0
1,455
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
SS Part A.docx
05/01/2014
Supporting Statement B
SS Part B.docx
05/01/2014
Information Sheet - English
Att 6 Info for Participants.English.doc
05/01/2014
Information Sheet - English screenshot
att 7 Info for Participants.Eng.Webscreen.pdf
05/01/2014
Information Sheet - Spanish
Att 8 Info for Participants.Spanish.docx
05/01/2014
Information Sheet - Spanish screenshot
Att 9 Info for Participants.Spanish.Webscreen.pdf
05/01/2014
Eligibility Screener - English word
Att 2 Eligib Screener.English.docx
05/01/2014
Eligibility Screener - Spanish word
Att 4 Eligib Screener.Spanish.docx
05/01/2014
Messages - English word
Att 10 Messages and Outcomes.English.docx
05/01/2014
Messages - Spanish word
Att 12 Messages and Outcomes.Spanish.docx
05/01/2014
Assessment - English word
Att 14 Assessment.English.docx
05/01/2014
Assessment - Spanish word
Att 16 Assessment.Spanish.docx
05/01/2014
Recruitment Materials
Att 18 Recruitment Materials.pdf
05/01/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.