Evauation of the I Can do It, You Can Do It Health Promotion Program fo Children and Youth with Disabilities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
icandoityoucandoit.doc	Supporting Statement B	Uploaded 2008-05-16	Available
0990-IcandoitShowPDF asp.pdf	Supplementary Document	Uploaded 2008-05-16	Available
expeditedrevombmemo5-7-08.doc	Supplementary Document	Uploaded 2008-05-16	Available
ICDISupporting Statement-rev5 7 08.doc	Supporting Statement A	Uploaded 2008-05-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
184945	Agency Coordinator Survey		New
184944	Mentor Post Assessment	Other-Form	New
184943	Second Post-Test Survey	Other-form	New
184942	Weekly Check-In Form	Other-form	New
184941	First Post-Test Survey	Other-test	New
184940	Pre-Test Survey		New
184939	Mentor Registration Form		New
184938	Goal Setting Worksheet (Program Participant/Mentee	Other-goal setting	New
184937	Registration Form (Program Participant/Mentee)	Other-registration form	New

ICR Details

OMB Control No: 0990-0328	ICR Reference No: 200805-0990-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Evauation of the I Can do It, You Can Do It Health Promotion Program fo Children and Youth with Disabilities
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 without change	Conclusion Date: 08/15/2008
	Date Received in OIRA: 05/19/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	36 Months From Approved
Responses	4,266	0	0
Time Burden (Hours)	885	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of this submission is to request OMB approval to conduct a longitudinal evaluation of participants in a helath promotion program developed by the Office on Disability(OD) targeted at children and youth with disabilities.

---

Authorizing Statute(s): PL: Pub.L. 106 - 310 317C Name of Law: null
   US Code: 42 USC 301 Name of Law: 241
   US Code: 42 USC 247b-4 Name of Law: null
  

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:
	73 FR 189	01/02/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 28471	05/16/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Second Post-Test Survey
Mentor Post Assessment
Agency Coordinator Survey
Mentor Registration Form
Pre-Test Survey
First Post-Test Survey
Weekly Check-In Form
Registration Form (Program Participant/Mentee)
Goal Setting Worksheet (Program Participant/Mentee

---

ICR Summary of Burden

table that charts list 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	4,266	0	0	4,266	0	0
Annual Time Burden (Hours)	885	0	0	885	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: New data collection

---

Annual Cost to Federal Government: $103,421

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: 05/19/2008

---