Document Name Document Type
HIV Testing Factors among Rural Black Men and Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth Form
Screener - Testing in Rural Black Men Att_1a_Screening and Contact Form.docx Form
Survey - Testing in Rural Black Men Att_1b_Survey Instrument.docx Form
Focus group guide - Testing in Rural Black Men Att_1c_Focus Group Guide.10012010.docx Form
Focus group guide - Family and Cultural Impact Att_1c_Focus Group Guide.docx Form
Focus group screener - Family and Cultural Impact Att_1a_Focus Group Screener.docx Form
Survey screener - Family and Cultural Impact Att_1b_Survey Screener.docx Form
Adult survey - Family and Cultural Impact Att_1d_ ACASI Survey-Parents.docx Form
Adolescent survey - Family and Cultural Impact Att_1e_ACASI Survey-Youth.docx Form
Brown_SS_SectA.OCT20.docx Supporting Statement - Testing in Rural Black Men IC Document
Att_4b_Local IRB Approval.pdf Local IRB Approval - Testing in Rural Black Men IC Document
Att_4c_Local IRB Approval.pdf Local IRB Approval - Testing in Rural Black Men IC Document
Att_4a_CDC Determination.pdf CDC Research Determination - Testing in Rural Black Men IC Document
Att_3a_Recruitment Flyer.10012010.docx Recruitment Flyer - Testing in Rural Black Men IC Document
Att_3b_Recruitment Script.10012010.docx Recruitment Script - Testing in Rural Black Men IC Document
Att_2a_Survey Consent.10012010.docx Survey Consent -Testing in Rural Black Men IC Document
Att_2b_Focus Group_Consent.10012010.docx Focus Group Consent - Testing in Rural Black Men IC Document
SS_Part A.docx Supporting Statement - Family and Cultural Impact IC Document
Att_3a_Project Determination-CDC.docx CDC determination - Family and Cultural Impact IC Document
Att_3b_Local IRB Determination.docx Local IRB - Family and Cultural Impact IC Document
Att_4a_Focus Group Recruitment Flyer.docx Focus group recruitment flyer - Family and Cultural Impact IC Document
Att_4b_Focus Group Recruitment Script.docx Focus group recruitment script - Family and Cultural Impact IC Document
Att_4d_Survey Recruitment Script.docx Survey recruitment script - Family and Cultural Impact IC Document
Att_4c_Survey Recruitment Flyer.docx Survey recruitment flyer - Family and Cultural Impact IC Document
Att_2a_ Focus Group Consent.docx Focus group consent - Family and cultural impact IC Document
Att_2b_Adult Survey Consent.docx Adult survey consent - Family and Cultural Impact IC Document
Att_2c_Adolescent Survey Assent .docx Adoloescent survey assent - Family and Cultural Impact IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIV Testing Factors among Rural Black Men and Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screener - Testing in Rural Black Men	Att_1a_Screening and Contact Form.docx	Yes	Yes	Fillable Fileable
Form	none	Adolescent survey - Family and Cultural Impact	Att_1e_ACASI Survey-Youth.docx	Yes	Yes	Fillable Fileable
Form	none	Survey - Testing in Rural Black Men	Att_1b_Survey Instrument.docx	Yes	Yes	Fillable Fileable
Form	none	Focus group guide - Testing in Rural Black Men	Att_1c_Focus Group Guide.10012010.docx	Yes	Yes	Fillable Fileable
Form	none	Focus group guide - Family and Cultural Impact	Att_1c_Focus Group Guide.docx	Yes	Yes	Fillable Fileable
Form	none	Focus group screener - Family and Cultural Impact	Att_1a_Focus Group Screener.docx	Yes	Yes	Fillable Fileable
Form	none	Survey screener - Family and Cultural Impact	Att_1b_Survey Screener.docx	Yes	Yes	Fillable Fileable
Form	none	Adult survey - Family and Cultural Impact	Att_1d_ ACASI Survey-Parents.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,858	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	3,858	0	0	0	0	0
Annual IC Time Burden (Hours)	2,310	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement - Testing in Rural Black Men	Brown_SS_SectA.OCT20.docx	12/13/2010
Local IRB Approval - Testing in Rural Black Men	Att_4b_Local IRB Approval.pdf	12/13/2010
Local IRB Approval - Testing in Rural Black Men	Att_4c_Local IRB Approval.pdf	12/13/2010
CDC Research Determination - Testing in Rural Black Men	Att_4a_CDC Determination.pdf	12/13/2010
Recruitment Flyer - Testing in Rural Black Men	Att_3a_Recruitment Flyer.10012010.docx	12/13/2010
Recruitment Script - Testing in Rural Black Men	Att_3b_Recruitment Script.10012010.docx	12/13/2010
Survey Consent -Testing in Rural Black Men	Att_2a_Survey Consent.10012010.docx	12/13/2010
Focus Group Consent - Testing in Rural Black Men	Att_2b_Focus Group_Consent.10012010.docx	12/13/2010
Supporting Statement - Family and Cultural Impact	SS_Part A.docx	12/13/2010
CDC determination - Family and Cultural Impact	Att_3a_Project Determination-CDC.docx	12/13/2010
Local IRB - Family and Cultural Impact	Att_3b_Local IRB Determination.docx	12/13/2010
Focus group recruitment flyer - Family and Cultural Impact	Att_4a_Focus Group Recruitment Flyer.docx	12/13/2010
Focus group recruitment script - Family and Cultural Impact	Att_4b_Focus Group Recruitment Script.docx	12/13/2010
Survey recruitment script - Family and Cultural Impact	Att_4d_Survey Recruitment Script.docx	12/13/2010
Survey recruitment flyer - Family and Cultural Impact	Att_4c_Survey Recruitment Flyer.docx	12/13/2010
Focus group consent - Family and cultural impact	Att_2a_ Focus Group Consent.docx	12/13/2010
Adult survey consent - Family and Cultural Impact	Att_2b_Adult Survey Consent.docx	12/13/2010
Adoloescent survey assent - Family and Cultural Impact	Att_2c_Adolescent Survey Assent .docx	12/13/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

HIV Testing Factors among Rural Black Men and Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth

Formative Research and Tool Development

OMB: 0920-0840

IC ID: 195746

View Information Collection (IC)