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Initial Participant Screening for Eligibility
Mobile Messaging Intervention to Present New HIV Prevention Options for Men Who have Sex with Men (MSM): Randomized Controlled Trial
OMB: 0920-1209
IC ID: 226271
OMB.report
HHS/CDC
OMB 0920-1209
ICR 201804-0920-012
IC 226271
( )
Documents and Forms
Document Name
Document Type
Initial Participant Screening for Eligibility
Form
Participant Screening
Att 4a_Participant Screening Form_02-15-2017.docx
Form
Screenshots of the Screening Form
Att 4g_M-Cubed P2 Screening Form Screenshots.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Initial Participant Screening for Eligibility
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
N/A
Participant Screening
Att 4a_Participant Screening Form_02-15-2017.docx
Yes
Yes
Fillable Fileable
Form
N/A
Screenshots of the Screening Form
Att 4g_M-Cubed P2 Screening Form Screenshots.pdf
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:
1,693
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
1,693
0
0
0
0
1,693
Annual IC Time Burden (Hours)
113
0
0
0
0
113
Annual IC Cost Burden (Dollars)
2,622
0
0
0
0
2,622
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.