Data Collection Instrument for Interviews

Formative Research to Inform an HIV Testing Social Marketing Campaign for African American Men Who Have Sex with Men (MSM)

0762_Att3a.WS-Part II - Interviews_081709

Data Collection Instrument for Interviews

OMB: 0920-0762

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PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail


This template is intended for staff without an ICRAS account. Please fill out and submit to the appropriate Operating Division to enter into ICRAS. The form mirrors the screens available in the ICRAS 4 system. To request an account to log into ICRAS.


Instructions for filling out the form are available at www.paperworkreduction.gov.






1. Title Formative Research to Inform an HIV Testing Social Marketing Campaign for African American Men Who Have Sex With Men (AAMSM) : Interviews


2. Is this a Common Form?


3. Obligation to respond (check one)


4. Frequency of reporting (check all that apply)



Yes


x No


a. x Voluntary


b. Required to obtain or retain benefits


c. Mandatory


a. Hourly (24 -7)

b. __ Hourly Bus (40 per week)

c. Daily (7 per week)

d. Daily Bus (5 per week)

e. Weekly (52 per year)

f. Monthly

g. Yearly

h. Every Decade

i. Quarterly

j. Semi-annually

k. Biennially

l.__x_ Once

m. ___ occasionally


5.CFR Citation(s) for the information collection under review (if applicable).

Title _______ Part __________________ Section________________________

Title _______ Part __________________ Section________________________

Title _______ Part __________________ Section________________________

Title _______ Part __________________ Section________________________





  1. Information Collection Instruments – Send all instruments along with the Part 2 form(s). If more than one Part 2 is completed make sure to identify which instruments are associated with which Part 2 form.

**Please refer to Attachment 3A in the Support Statement for the Data Collection Instruments.





7. Federal Enterprise Architecture Business Reference Model (Select one Services for Citizens Line of Business and one Subfunction from its group)

Services for Citizens Line of Business

Subfunction

None


Community and Social Services___

Homeownership Promotion___

Community and Regional Development___

Social Services___

Postal Service___

None___

Correctional Activities___

Criminal Incarceration

Criminal Rehabilitation

None

Defense and National Security___

Strategic National and Theater Defense___

Operational Defense___

Tactical Defense___

None___

Disaster Management___

Disaster Monitoring and Predication___

Disaster Preparedness and Planning___

Disaster Repair and Restore___

Emergency Response___

None___

Economic Development___

Business and Industry Development___

Intellectual Property Protection___

Financial Sector Oversight___

Industry Sector Income Stabilization___

None___

Education___

Elementary, Secondary, and Vocational Education___

Higher Education___

Cultural and Historic Preservation___

Cultural and Historic Exhibition___

None___

Energy___

Energy Supply___

Energy Conservation and Preparedness___

Energy Resource Management___

Energy Production___

None___

Environmental Management___

Environmental Monitoring and Forecasting___

Environmental Remediation___

Pollution Prevention and Control___

None___

General Science and Innovation___

Scientific and Technological Research and Innovation___

Space Exploration and Innovation ___

None___

Health_x__

Illness Prevention_x__

Immunization Management___

Public Health Monitoring___

Health Care Services___

Consumer Health and Safety___

None___

Homeland Security___

Border and Transportation Security___

Key Asset and Critical Infrastructure Protection___

Catastrophic Defense___

None___

Income Security___

General Retirement and Disability___

Unemployment Compensation___

Housing Assistance___

Food and Nutrition Assistance___

Survivor Compensation___

None___

Intelligence Operations___

Intelligence Planning and Direction/Needs___

Intelligence Collection___

Intelligence Analysis and Production___

Dissemination___

None___

International Affairs and Commerce___

Foreign Affairs___

International Development and Humanitarian Aid___

Global Trade___

None___

Law Enforcement___

Criminal Apprehension___

Criminal Investigation and Surveillance___

Citizen Protection___

Crime Prevention___

Leadership Protection___

Property Protection___

Substance Control___

None___

Litigation and Judicial Activities___

Judicial Hearing___

Legal Defense___

Legal Investigation___

Legal Prosecution and Litigation___

Resolution Facilitation ___

None___

Natural Resources___

Water Resource Management___

Conservation, Marine and Land Management___

Recreational Resource Management and Tourism___

Agricultural Innovation and Services___

None___

Transportation___

Air Transportation___

Ground Transportation___

Water Transportation___

Space Operations___

None___

Workforce Management___

Training and Employment___

Labor Rights Management___

Worker Safety___

None___


See http://www.feapmo.gov for the Business Reference Model categories and definitions.



8. Privacy Act System of Records (if applicable)


Title:

Federal Register Citation: Volume ________ Page number ____________ Publication date / /____




9. Respondents: Interviews














a. Total # 144

b. Small Entity # 0 _________

c. Percent Electronic 0 ____________


Affected public (choose one)
a.
X Individuals or households

b. Private Sector
c.
State, Local, or Tribal Governments
d.
Federal Government

(if Private Sector check all that apply)
a.
Business or other for-profits
b.
Not-for-profit institutions
c.
Farms


10. Frequency: How often on average will each respondent respond to the Information Collection?

Number of Responses per Respondent __1__

Per (select the most appropriate time period for this collection)

a. Hour (24-7) - 8736 per year

b. Business Hour (40 per week) - 2080 per year

c. Day (7 per week) - 364 per year

d. Business Day (5 per week) - 260 per year

e. Week - 52 per year

f. Month - 12 per year

g. 1 Year

h. Decade .1 per year

i. Quarter - 4 per year

j. Half-Year - 2 per year

k. Biennial - 0.5 per year


Calculated: Annual Frequency =__144______________ (per respondent)

Calculated: Annual Number Of Responses = __144 _______________





11. Hour and Cost Burden

Enter the hours and cost (per response) broken out by reporting, record keeping, and third-party disclosure.


Time per Response

Hour per response

Annual Hour Burden

Cost per Response

Annual cost Burden

Reporting.

1 hour

1

144

$6.00

$864.00

Record keeping

n/a

n/a

n/a

n/a

n/a

Third party disclosure

n/a

n/a

n/a

n/a

n/a

Total

1 hour

1

144

$6.00

$864.00







  1. Allocate the change in burden



n/a


Total Requested

Change Due to

New Statute


Change Due to

Agency Discretion


Due to

Agency Estimate


Change Due

Violation


Currently Approved



a. Annual Responses

144

0


108






36



b. Annual Hour Burden

144



36hours


hours


hours


180 hours



c. Annual Cost Burden

$864



$ 648


$


$


$ 216





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File Typeapplication/msword
File TitlePart II Worksheet: Information Collection Detail
AuthorPeyton Williams
Last Modified Bytfs4
File Modified2009-08-17
File Created2009-08-17

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