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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Observational Program Implementation Fidelity Measure	Form	Modified	Available
Facilitator Program Implementation Fidelity Measure	Form	Modified	Available
Att D - Baseline Survey	Form	Modified	Available
Form 2 Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)	Form	Modified	Available
Completion Survey	Form	Modified	Available
Att E - Completion and Follow up Survey	Form	Removed	Available
Completion and Follow-up Survey (12 month)	Form	Modified	Available
ERSG OMB SSA 9.15.11 Clean Version.docx	Supplementary Document	Uploaded 2011-10-11	Available
ERSG Change Request 9-27-11.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-10-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197246	ERSG Observational Program Implementation Fidelity Measure	Form	Modified	Observational Program Implementation Fidelity Measure
197245	ERSG Facilitator Program Implementation Fidelity Measure	Form	Modified	Facilitator Program Implementation Fidelity Measure
194255	Teen Dating Violence Support Group Evaluation Survey (Baseline Survey)	Form	Modified	Att D - Baseline Survey
194254	Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)	Form	Modified	Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)
194253	Teen Dating Violence Support Group Evaluation Survey (Completion Survey)	Form	Modified	Completion Survey
194252	Teen Dating Violence Support Group Evaluation Survey (18-Month Follow Up Survey)	Form	Removed	Att E - Completion and Follow up Survey
194251	Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey)	Form	Modified	Completion and Follow-up Survey (12 month)

ICR Details

OMB Control No: 0920-0861	ICR Reference No: 201110-0920-005
Status: Historical Active	Previous ICR Reference No: 201104-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: A Controlled Evaluation of Expect Respect Support Groups (ERSG): Preventing and Interrupting Teen Dating Violence among At-Risk Middle and High School Students
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/14/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/14/2011
Terms of Clearance: Previous terms continue: Approved with the understanding that CDC will maintain a strong oversight role in the evaluation of the intervention.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2013	08/31/2013	08/31/2013
Responses	2,232	0	2,632
Time Burden (Hours)	1,608	0	2,008
Cost Burden (Dollars)	0	0	0

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Abstract: Changes requested include rewording some of the survey questions and instructions and eliminating the 18 month follow-up survey.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Research and Investigation 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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
ERSG Facilitator Program Implementation Fidelity Measure	none	Facilitator Program Implementation Fidelity Measure
ERSG Observational Program Implementation Fidelity Measure	none	Observational Program Implementation Fidelity Measure
Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)	2	Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)
Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey)	none	Completion and Follow-up Survey (12 month)
Teen Dating Violence Support Group Evaluation Survey (18-Month Follow Up Survey)	none	Att E - Completion and Follow up Survey
Teen Dating Violence Support Group Evaluation Survey (Baseline Survey)	none	Att D - Baseline Survey
Teen Dating Violence Support Group Evaluation Survey (Completion Survey)	none	Completion Survey

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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	2,232	2,632	0	-400	0	0
Annual Time Burden (Hours)	1,608	2,008	0	-400	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: CDC has decided to eliminate the 18-month follow-up survey resulting in a burden reduction of 400 hours.

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Annual Cost to Federal Government: $227,005

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: 10/14/2011

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