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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Evaluating HIV/AIDS Focused Video Game for Young People
Agency IC Tracking Number:
15VI
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR Publlic Health Service Act (To search for a specific CFR, visit the
Code of Federal Regulations.
)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
none
Enrollment Day Survey
Att_3b_ParticipantEnrollment Day Survey_Clean.docx
No
Paper Only
Form
none
Experimental Group Survey
Att_3c_Experimental Group Immediate Post Survey.docx
No
Paper Only
Form
none
30 Day Post Survey
Att_3d_Participant 30 Day Post Survey_Clean.docx
No
Paper Only
Form
none
Demographic Screener
Att_3a_ParticipantEligibilityForm_Clean.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
700
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
700
0
700
0
0
0
Annual IC Time Burden (Hours)
129
0
129
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
SS Part A
SS_Part A (2)_Clean.docx
06/05/2015
SS Part B
SS_Part B_OMB_CLEAN.docx
06/05/2015
Legislation
Att 1_Authorizing Legislation.pdf
03/20/2015
IRB Approval
Att_5a_ CDC 6701 IRB Approval.pdf
03/20/2015
Parental Consent
Att_2a_Parent Consent.docx
03/20/2015
Adolescent Consent
Att_2b_Adolescent Assent.docx
03/20/2015
Adult Consent
Att_2c_Adult Consent.docx
03/20/2015
Recruitment Flyer
Att_4a_Study Recruitment Flyer.docx
03/25/2015
Screen Shots
Att_6a_Game Screen Shots.docx
06/05/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.