Information Collection Request

A Controlled Evaluation of Expect Respect Support Groups (ERSG): Preventing and Interrupting Teen Dating Violence among At-Risk Middle and High School Students

ICR 201008-0920-004 · OMB 0920-0861 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 3 Baseline Evaluation Survey Form and Instruction New Available
Form 2 Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment) Form New Available
Form 1 Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form and Instruction New Available
Form 1 Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form and Instruction New Available
Form 1 Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form and Instruction New Available
ERSG OMB SSB.docx Supporting Statement B Uploaded 2010-07-27 Available
Attachment H - Expect Respect Safety Procedures and Mandatory Reporting Requirements 7.19.10.doc Supplementary Document Uploaded 2010-07-27 Available
Attachment G - Student Assent Form and Parent Notification Form (v3).doc Supplementary Document Uploaded 2010-07-27 Repair queued
Attachment F - IRB approvals.docx Supplementary Document Uploaded 2010-07-27 Available
Attachment I - Published 30-day FRN.pdf Supplementary Document Uploaded 2010-07-27 Available
Attachment B - Federal Register Notice.pdf Supplementary Document Uploaded 2010-07-27 Available
Attachment A - PHS Act Sec 301.pdf Supplementary Document Uploaded 2010-07-27 Available
ERSG OMB SSA.docx Supporting Statement A Uploaded 2010-07-27 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
194255 Teen Dating Violence Support Group Evaluation Survey (Baseline Survey) Form and Instruction NewBaseline Evaluation Survey
194254 Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment) Form NewIntake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)
194253 Teen Dating Violence Support Group Evaluation Survey (Completion Survey) Form and Instruction NewTeen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey)
194252 Teen Dating Violence Support Group Evaluation Survey (18-Month Follow Up Survey) Form and Instruction NewTeen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey)
194251 Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form and Instruction NewTeen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey)

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2013 36 Months From Approved
2,600 0 0
2,000 0 0
0 0 0





Reginfo record details
5
table that charts list of burden
IC Title Form No. Form Name
Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment) 2
Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) 1
Teen Dating Violence Support Group Evaluation Survey (18-Month Follow Up Survey) 1
Teen Dating Violence Support Group Evaluation Survey (Baseline Survey) 3
Teen Dating Violence Support Group Evaluation Survey (Completion Survey) 1

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 2,600 0 0 2,600 0 0
Annual Time Burden (Hours) 2,000 0 0 2,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No