OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Multi-site HIV Testing in Community Mental Health Settings Serving African Americans

ICR 200905-0920-003 · OMB 0920-0833 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form No number Core Questionnaire Form New Available
Form no number Consent Questionnaire Form New Available
Form no number Eligibility Screener Form New Repair queued
OMB Response_Comments_MultiSiteHIV_113009.doc Supplementary Document Uploaded 2009-12-04 Available
OMB Response_ICR_MultiSiteHIV_113009_clean.doc Supplementary Document Uploaded 2009-12-04 Available
92008BL-OMB Supporting Statement B_ 042009.doc Supporting Statement B Uploaded 2009-05-06 Repair queued
Att 9 References.doc Supplementary Document Uploaded 2009-05-06 Available
Att 8 Model Consent.doc Supplementary Document Uploaded 2009-05-06 Available
Att 7 Restrictions on Release of Data.doc Supplementary Document Uploaded 2009-05-06 Available
Att 6 Assurance of Confidentiality.doc Supplementary Document Uploaded 2009-05-06 Repair queued
Att 5E Sheppard Pratt IRB_Baltimore.doc Supplementary Document Uploaded 2009-05-06 Available
Att 5D University of Pennsylvania IRB.pdf Supplementary Document Uploaded 2009-05-06 Repair queued
Att 5C University of Maryland IRB.pdf Supplementary Document Uploaded 2009-05-06 Repair queued
Att 5B Philadelphia City IRB.pdf Supplementary Document Uploaded 2009-05-06 Repair queued
Att 5A CDC IRB Approval.doc Supplementary Document Uploaded 2009-05-06 Available
Att 4 Consultants.doc Supplementary Document Uploaded 2009-05-06 Available
Att 2d Comment to Revised FRN_2008.doc Supplementary Document Uploaded 2009-05-06 Repair queued
Att 2c Revised 60-Day FRN_2008.pdf Supplementary Document Uploaded 2009-05-06 Repair queued
Att 2b Comment to FRN.doc Supplementary Document Uploaded 2009-05-06 Available
Att 2a Initial 60-Day FRN.pdf Supplementary Document Uploaded 2009-05-06 Available
Att 1 PHSA.pdf Supplementary Document Uploaded 2009-05-06 Available
OMB Response_ICR_MultiSiteHIV_113009_marked.doc Supporting Statement A Uploaded 2009-12-07 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
189385 Core Questionnaire Form New
189384 Consent Questionnaire Form New
189383 Eligibility Screener Form New
ICR Details
0920-0833 200905-0920-003
Historical Active
HHS/CDC
Multi-site HIV Testing in Community Mental Health Settings Serving African Americans
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 12/08/2009
Retrieve Notice of Action (NOA) 05/29/2009
  Inventory as of this Action Requested Previously Approved
12/31/2011 24 Months From Approved
1,856 0 0
313 0 0
0 0 0
People with severe mental illness (SMI) are at increased risk of HIV infection compared with the general population. Despite the risk of comorbidity, persons with SMI are often not included when planning and implementing HIV programs and interventions by health agencies. Mental health care settings are important for HIV testing and promoting prevention efforts. This project will implement HIV testing programs in 6 mental health settings in Balitmore and Philadelphia. Testing and linkage to treatment services will be offered to those receiving mental health services in a hospital psychiatry inpatient unit; a community-based outpatient clinic, and outreach program. Approximately 1200 clients will be enrolled over 2 years. The data wil help inform the development of HIV testing and prevention programs in settings that serve persons with SMI.
US Code: 42 USC 301 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  73 FR 45226 08/04/2008
74 FR 21810 05/11/2009
Yes
3
IC Title Form No. Form Name
Eligibility Screener no number Eligibility Screener
Consent Questionnaire no number Consent questionnaire
Core Questionnaire No number Core questionnaire
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,856 0 0 1,856 0 0
Annual Time Burden (Hours) 313 0 0 313 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new data collection.
$353,998
Yes Part B of Supporting Statement
Yes
Uncollected
Uncollected
No
Uncollected
Maryam Daneshvar 4046394604
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
05/29/2009