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

Forms and Documents

Document Name	Status
Success Case Study Consent Form	New
RCT Consent Form	New
Success Case Study Interview Form	Modified
6-Month Follow-up Questionnaire Form	Modified
3-Month Follow-up Questionnaire Form	Modified
Client Satisfaction Survey Form	Modified
Participant Contact Information Form Form	Modified
Baseline Questionnaire Form	Modified
Limited Locator Form Form	Modified
Outreach Recruitment Assessment Form	Modified
SS A Clean.docx Supporting Statement A	2014-12-04
Att 5b_Project Determination approval.pdf Supplementary Document	2014-11-20
Att 5a_MLMS IRB approval.pdf Supplementary Document	2014-11-20
Att 3k_Follow-up interview log.docx Supplementary Document	2014-11-20
Att 3j_Participant Contact Log.docx Supplementary Document	2014-11-20
Att 3a_Data Collection Flowchart.docx Supplementary Document	2014-11-20
Att 2a_Public Comment.docx Supplementary Document	2014-11-20
Att 2_60 Day FRN.pdf Supplementary Document	2014-11-20
Att 1_Public Health Service Act.docx Supplementary Document	2014-11-20
SS B Clean.docx Supporting Statement B	2014-11-20

IC Document Collections

IC ID	Document Title	Status
213999	Success Case Study Consent Form	New
213998	RCT Consent Form	New
199775	Success Case Study Interview Form	Modified
199774	6-Month Follow-up Questionnaire Form	Modified
199773	3-Month Follow-up Questionnaire Form	Modified
199772	Client Satisfaction Survey Form	Modified
199771	Participant Contact Information Form Form	Modified
199770	Baseline Questionnaire Form	Modified
199769	Limited Locator Form Form	Modified
199768	Outreach Recruitment Assessment Form	Modified

ICR Details

OMB Control No: 0920-0913	ICR Reference No: 201411-0920-009
Status: Historical Active	Previous ICR Reference No: 201204-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/09/2015
	Date Received in OIRA: 12/04/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	12 Months From Approved	01/31/2015
Responses	598	0	3,984
Time Burden (Hours)	459	0	1,662
Cost Burden (Dollars)	0	0	0

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Abstract: Extension request to complete enrollment of about 10 men to reach desired sample size and complete all follow-up surveys and interviews.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 49519	08/21/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 70190	11/25/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
Outreach Recruitment Assessment	none	Outreach Recruitment Assessment
Limited Locator Form	none	Limited Locator Information
Baseline Questionnaire	none	Baseline Questionnaires
Participant Contact Information Form	none	Participant Contact Information
Client Satisfaction Survey	none	Client Satisfaction Survey
3-Month Follow-up Questionnaire	none	3 month Follow-up Questionnaire
6-Month Follow-up Questionnaire	none	6 month Follow-up Questionnaire
Success Case Study Interview	none	Success Case Study Interview
RCT Consent	none	RCT Consent
Success Case Study Consent	none	Success Case Study Consent

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ICR Summary of Burden

	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	598	3,984	0	0	-3,386	0
Annual Time Burden (Hours)	459	1,662	0	0	-1,203	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This extension request is to continue the study to reach the desired sample size. New ICs are just a different ICR presentation; burden hours are off by one hour due to rounding in ROCIS.

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Annual Cost to Federal Government: $663,908

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/04/2014

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