Web-based Approaches to Reach Black or African American and Hispanic/Latino MSM for HIV Testing and Prevention Services

Forms and Documents

Document Name	Status
Form 0920- Guest HIV Test Result Survey Form and Instruction	New
Form 0920- Guest Consent Form Form and Instruction	New
Form 0920- Product Ordering Form and Instruction	New
Form 0920- Final HIV Test Result Survey (completion) Form and Instruction	New
Form 0920- Follow-up Form and Instruction	New
Form 0920- Initial HIV Test Result Survey Form and Instruction	New
Form 0920- Baseline Survey Form and Instruction	New
Form 0920- Registration Contact Information Form and Instruction	New
Form 0920- Study Consent Form and Instruction	New
Form 0920- Eligibility Screener Form and Instruction	New
Form 0920- Eligibility Consent Form and Instruction	New
SS A FINAL 03FEB2020.docx Supplementary Document	2020-02-03
Att 6_Screenshots.docx Supplementary Document	2019-07-25
Att 5c_Data Sharing Agreement.doc Supplementary Document	2019-07-25
Att 3b_Registration contact info.docx Supplementary Document	2019-07-25
Att 2a_Public Comment_Whitman_Walker Comments _ Docket No. CDC_2018_0102.pdf Supplementary Document	2019-07-25
Att 5b_PIA_Form_iSTAMP approved (03-04-2019).pdf Supplementary Document	2019-07-18
Att 5a_Emory IRB Approval.pdf Supplementary Document	2019-07-18
Att 2_60 Day FRN.pdf Supplementary Document	2019-07-18
Att 1_Authorizing Legislation.docx Supplementary Document	2019-07-18
SS B_FINAL_rev020419.docx Supporting Statement B	2020-02-04
SS A FINAL 03FEB2020.docx Supporting Statement A	2020-02-03

IC Document Collections

IC ID	Document Title	Status
237106	Guest HIV Test Result Survey Form and Instruction	New
237105	Guest Consent Form Form and Instruction	New
237104	Product Ordering Form and Instruction	New
237099	Final HIV Test Result Survey (completion) Form and Instruction	New
237098	Follow-up Form and Instruction	New
237096	Initial HIV Test Result Survey Form and Instruction	New
237094	Baseline Survey Form and Instruction	New
237093	Registration Contact Information Form and Instruction	New
237091	Study Consent Form and Instruction	New
237025	Eligibility Screener Form and Instruction	New
237024	Eligibility Consent Form and Instruction	New

ICR Details

OMB Control No: 0920-1284	ICR Reference No: 201907-0920-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-19BG
Title: Web-based Approaches to Reach Black or African American and Hispanic/Latino MSM for HIV Testing and Prevention Services
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/07/2020
	Date Received in OIRA: 07/25/2019
Terms of Clearance: Approved consistent with the understanding that CDC will not be conducting any general research on the information collected. When communicating findings from this collection, all publications will clearly describe the scope and limitations of the study findings.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2023	36 Months From Approved
Responses	15,200	0	0
Time Burden (Hours)	1,517	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this study is to evaluate the effectiveness of mailing out rapid HIV home-testing kits and additional testing promotion components to increase HIV testing among black/African American and Hispanic/Latino MSM. The findings from this research will assist local and state health departments and community-based organizations in making decisions on how to improve HIV testing and linkage to HIV prevention services for black/African American and Hispanic/Latino MSM in the United States.

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Authorizing Statute(s): None

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:
	83 FR 62864	12/06/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 32918	07/19/2019
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 11

IC Title	Form No.	Form Name
Baseline Survey	0920-	Baseline Survey
Study Consent	0920-	Study Consent
Follow-up	0920-	Follow-up Survey
Guest HIV Test Result Survey	0920-	Guest HIV Test Result Survey
Initial HIV Test Result Survey	0920-	Initial HIV Test Result Survey
Final HIV Test Result Survey (completion)	0920-	Final HIV Test Result Survey
Product Ordering	0920-	Product Ordering
Registration Contact Information	0920-	Registration Contact Information
Guest Consent Form	0920-	Guest Consent
Eligibility Consent	0920-	Eligibility Consent
Eligibility Screener	0920-	Eligibility Screener

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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	15,200	0	0	15,200	0	0
Annual Time Burden (Hours)	1,517	0	0	1,517	0	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: No

Burden Reduction Due to:

Short Statement: This is a NEW information collection request.

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Annual Cost to Federal Government: $948,200

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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: 07/25/2019

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