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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Developing Tools to Engage Adolescent Men Who Have Sex with Men (AMSM)
Agency IC Tracking Number:
0920-17AZE
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
n/a
Screener for In-person AMSM and Transgender Focus Groups
Att 3a. Screener (In-Person Focus Groups).docx
No
Paper Only
Form
n/a
Screener for Online AMSM and Transgender Focus Groups
Att 3a. Screenshots of Screener (Online Focus Groups).docx
Yes
Yes
Fillable Fileable
Form and Instruction
n/a
AMSM Focus Group Guide
Att 3b. AMSM Focus Group Guide.docx
No
Paper Only
Form
n/a
Screenshots of AMSM Focus Group Guide
Att 3b. Screenshots of AMSM Focus Group Guide.docx
Yes
Yes
Fillable Fileable
Form and Instruction
n/a
Transgender Youth Focus Group Guide
Att 3c. Transgender Youth Focus Group Guide.docx
No
Paper Only
Form
n/a
Screenshots of Transgender Youth Focus Group Guide
Att 3c. Screenshots of Transgender Youth Focus Group Guide.docx
Yes
Yes
Fillable Fileable
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. HHS/CDC
FR Citation:
57 FR 62812
Number of Respondents:
72
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
67 %
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
72
0
72
0
0
0
Annual IC Time Burden (Hours)
198
0
198
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement Part A
SSA.docx
10/04/2017
Supporting Statement Part B
SSB.docx
10/04/2017
Federal Register Notice
Att 2--Federal Register Notice.pdf
10/04/2017
Informed Consent for Participants 18 and Over
Att 4a. Informed Consent.docx
10/04/2017
Screenshots of Informed Assent or Consent
Att 4a. 4b. Screenshots of Informed Assent Forms.docx
10/04/2017
Waiver or Alteration of Informed Consent
Att 4c. Waiver Informed Consent.doc
10/04/2017
Waiver of Parental Permission
Att 4d. Waiver of Parental Permission.doc
10/04/2017
Waiver of HIPAA Authorization
Att 4e. Waiver HIPAA Authorization.doc
10/04/2017
Procedure for Reporting Suspected Child Abuse
Att 4f. Procedure for Reporting Child Abuse.doc
10/04/2017
Recruitment Advertisements
Att 5a. Focus Group Recruitment Ads.pptx
10/04/2017
Online Recruitment Ad Language
Att 5b. Recruitment Language.docx
10/04/2017
IRB Approval Letter
Att 6a. The Fenway Institute IRB Approval Letter.pdf
10/04/2017
Informed Assent for Participants Under 18 Years of Age
Att 4b. Informed Assent.docx
10/05/2017
CDC Research Project Determination Form
Att 6b. CDC HumanSubject Project Determination_2017.10.06.pdf
10/06/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.