Community-based Organization (CBO) Monitoring and Evaluation Project (CMEP) of WILLOW (CMEP-WILLOW)

Forms and Documents

Document Name	Status
Form 7 180-day Follow-up Form and Instruction	New
Form 6 90-day Follow-up Interview Form and Instruction	New
Form 3 Baseline Survey Form and Instruction	New
Form 1 Eligibility Screener Form and Instruction	New
0920-New_SS-Part B.doc Supporting Statement B	2011-08-08
0920-New_att4_Participation Agreement.pdf Supplementary Document	2011-08-08
0920-New_SS-Part A_080411_WILLOW-Revised 8.5.11.DOC Supporting Statement A	2011-08-08

IC Document Collections

IC ID	Document Title	Status
198815	180-day Follow-up Interview--Grantee Other-Screen Shot	New
198814	180-day Follow-up Form and Instruction	New
198813	90-day Follow-up Interview--Grantees Other-screen shot	New
198812	90-day Follow-up Interview Form and Instruction	New
198811	Baseline Survey--Grantees Other-Screen shot	New
198810	Baseline Survey Form and Instruction	New
198809	Eligibility Screener--Grantees Other-screen shot	New
198808	Eligibility Screener Form and Instruction	New

ICR Details

OMB Control No: 0920-0896	ICR Reference No: 201108-0920-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Community-based Organization (CBO) Monitoring and Evaluation Project (CMEP) of WILLOW (CMEP-WILLOW)
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: 08/12/2011
	Date Received in OIRA: 08/09/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	36 Months From Approved
Responses	1,732	0	0
Time Burden (Hours)	358	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Community-based Organization (CBO) Monitoring and Evaluation Project (CMEP) of WILLOW has two purposes: 1) to monitor changes in client's self-reported HIV risk behaviors and attitudes after participating in the Effective Behavioral Intervention (EBI) WILLOW as delivered by CDC-funded CBOs and 2) to assess the fidelity of the delivery of WILLOW at CBOs. From July 2010 through July 2015, CMEP will provide additional funds through FOA 10-1003 to four CBOs to collect outcome monitoring data from 400 women who are living with HIV and participating in WILLOW as well as process and fidelity assessment data about the implementation of the interventions. CMEP-WILLOW will employ a repeated measures design to collect client-level data before the intervention and then again at three-months and six-months following the intervention. Findings will help to further understanding of how these interventions are delivered once they leave the research arena and whether or not they are associated with behavior change. Ultimately this information will help CBOs improve their intervention delivery and better serve clients.

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Authorizing Statute(s): PL: Pub.L. 111 - 241 301 Name of Law: Research and Investigations Generally
  

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:
	76 FR 6139	02/03/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 18553	04/04/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
90-day Follow-up Interview	6	90-day Follow-up Interview
90-day Follow-up Interview--Grantees
Eligibility Screener	1	Eligibility Screener
Eligibility Screener--Grantees
180-day Follow-up	7	180-day Follow-up Interview
Baseline Survey	3	Baseline Survey
Baseline Survey--Grantees
180-day Follow-up Interview--Grantee

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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	1,732	0	0	1,732	0	0
Annual Time Burden (Hours)	358	0	0	358	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 ICR.

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Annual Cost to Federal Government: $753,475

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? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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: 08/09/2011

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