OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles

ICR 201204-0920-004 · OMB 0920-0913 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Change Request-030812.docx Justification for No Material/Nonsubstantive Change Uploaded 2012-04-19 Available
Attachment 4b Success Case Study Informed Consent Form 6.15.11.docx Supplementary Document Uploaded 2011-10-14 Available
Att 3j Follow-up interview log 082511.docx Supplementary Document Uploaded 2011-10-14 Available
Att 3j Follow-up interview log 082511.docx Supplementary Document Uploaded 2011-10-14 Available
Att 3i Participant Contact Log 082511.docx Supplementary Document Uploaded 2011-10-14 Repair queued
Attachment 4a MyLife, MyStyle Informed Consent Form 6.15.11.docx Supplementary Document Uploaded 2011-10-14 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
199775 Success Case Study Interview Other-WORD Modified
199774 6-Month Follow-up Questionnaire Other-WORD Modified
199773 3-Month Follow-up Questionnaire Other-WORD Modified
199772 Client Satisfaction Survey Other-WORD Modified
199771 Participant Contact Information Form Other-WORD Modified
199770 Baseline Questionnaire Other-WORD Modified
199769 Limited Locator Form Other-WORD Modified
199768 Outreach Recruitment Assessment Other-WORD Modified
ICR Details
0920-0913 201204-0920-004
Historical Active 201110-0920-008
HHS/CDC
Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/23/2012
Retrieve Notice of Action (NOA) 04/23/2012
  Inventory as of this Action Requested Previously Approved
01/31/2015 01/31/2015 01/31/2015
3,984 0 3,984
1,662 0 1,662
0 0 0
This is a request to make minor changes to some of the forms based on feedback.
US Code: 42 USC 301 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
Yes
  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 3,984 3,984 0 0 0 0
Annual Time Burden (Hours) 1,662 1,662 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$663,908
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Thelma Sims 4046394771
  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.
04/23/2012