Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence

Forms and Documents

Document Name	Status
Form No number Employee Survey Form and Instruction	New
Form No number Manager Survey Form and Instruction	New
Supporting Statement Part B.doc Supporting Statement B	2008-01-23
Appendix D_IPV Workplace.1.21.08.doc Supplementary Document	2008-01-23
Appendix J _Workplace OMB Package_1.21.08.pdf Supplementary Document	2008-01-23
Appendix L_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document	2007-11-02
Appendix K_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document	2007-11-02
Appendix I_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document	2007-11-02
Appendix H_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document	2007-11-02
Appendix G_IPV Workplace OMB Package 10 18 07.doc Supplementary Document	2007-11-02
Appendix F_IPV Workplace OMB Package 10 21 07..pdf Supplementary Document	2007-11-02
Appendix B_IPV Workplance OMB Package 10 22 07.doc Supplementary Document	2007-11-02
Appendix E_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document	2007-11-02
Supporting Statement Part A.doc Supporting Statement A	2008-01-29

IC Document Collections

IC ID	Document Title	Status
183664	Employee Survey Form and Instruction	New
183663	Manager Survey Form and Instruction	New

ICR Details

OMB Control No: 0920-0789	ICR Reference No: 200802-0920-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence
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: 08/25/2008
	Date Received in OIRA: 02/01/2008
Terms of Clearance: Approved consistent with CDC response to OMB with the following terms of clearance: the survey will not be used to generate representative estimates, CDC is reminded to seek OMB approval prior to data collection, OMB does not approve the proposed lottery incentive.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	13 Months From Approved
Responses	3,000	0	0
Time Burden (Hours)	1,125	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Intimate partner violence (IPV) affects a substantial number of Americans, and there has recently been increasing recognition of the impact it has on the workplace. The purpose of the proposed evaluation is to document in detail the workplace IPV prevention activities delivered by the company, to determine the impact of these activities on short-term and long-term outcomes, and to determine the cost-effectiveness of the program.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 10219	03/07/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 63610	11/09/2007
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Manager Survey	No number	Manager Survey
Employee Survey	No number	No name

---

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	3,000	0	0	3,000	0	0
Annual Time Burden (Hours)	1,125	0	0	1,125	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 data collection.

---

Annual Cost to Federal Government: $293,820

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 02/01/2008

---