Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 38 Community Capacity and Readiness	Form	New	Repair queued
Form 37 Parent Program Capacity and Readiness	Form	New	Repair queued
Form 36 Local Health Department Capacity and Readiness	Form	New	Repair queued
Form 35 Communications Campaign Tracking	Form	New	Available
Form 25 Student Program Fidelity 8th, Grade, Session 1-10	Form	New	Repair queued
Form 24 Student Program Fidelity 7th, Grade, Session 1-6	Form	New	Repair queued
Form 13 Student Program Fidelity 6th Grade, Sessions 1-6	Form	New	Available
Form 12 Safe Dates Implementation Survey	Form	New	Repair queued
Form 11 Parent Program Fidelity 7th Grade Sessions 1,3,5	Form	New	Available
Form 9 Parent Program Fidelity 6th Grade Sessions 1-5	Form and Instruction	New	Available
Form 7 School Leadership Capacity and Readiness Survey	Form and Instruction	New	Repair queued
Form 6 Brand Ambassador Implementation Survey	Form and Instruction	New	Repair queued
Form 5 Educator Outcome Survey	Form and Instruction	New	Available
Form 4 Parent Outcome Survey	Form and Instruction	New	Repair queued
Form 3 School Indicators	Form	New	Available
Form 2 Student Outcome Survey Follow-up	Form and Instruction	New	Repair queued
Form 1 Student Outcome Survey Baseline	Form and Instruction	New	Available
SuppStatement B rev.docx	Supporting Statement B	Uploaded 2011-10-21	Available
Attachment Z2 - Student+Program+Fidelity+7th+Grade+Session+1.docx	Supplementary Document	Uploaded 2011-10-24	Available
Attachment VV - Parent+Consent+for+Parent+Form.docx	Supplementary Document	Uploaded 2011-10-21	Available
Attachment UU - Parent+Consent+for+Student+Form.docx	Supplementary Document	Uploaded 2011-10-21	Repair queued
Attachment TT - Student+Assent+Form.docx	Supplementary Document	Uploaded 2011-10-21	Repair queued
SuppStatement A rev.docx	Supporting Statement A	Uploaded 2011-10-21	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199982	Community Capacity and Readiness	Form	New
199981	Parent Program Capacity and Readiness	Form	New
199980	Local Health Department Capacity and Readiness	Form	New
199979	Communications Campaign Tracking	Form	New
199978	Student Program Fidelity 8th, Grade, Session 1-10	Form	New
199977	Student Program Fidelity 7th, Grade, Session 1-6	Form	New
199976	Student Program Fidelity 6th Grade, Sessions 1-6	Form	New
199975	Safe Dates Implementation Survey	Form	New
199974	Parent Program Fidelity 7th Grade Sessions 1,3,5	Form	New
199973	Parent Program Fidelity 6th Grade Sessions 1-5	Form and Instruction	New
199972	School Leadership Capacity and Readiness Survey	Form and Instruction	New
199971	Brand Ambassador Implementation Survey	Form and Instruction	New
199970	Educator Outcome Survey	Form and Instruction	New
199969	Parent Outcome Survey	Form and Instruction	New
199968	School Indicators	Form	New
199967	Student Outcome Survey Follow-up	Form and Instruction	New
199966	Student Outcome Survey Baseline	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 201110-0920-012
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships
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: Withdrawn	Conclusion Date: 12/21/2011
	Date Received in OIRA: 10/31/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Dating Matters is a comprehensive approach to prevent teen dating violence among youth in high-risk urban communities. Dating Matters consists of evidence-based or evidence-informed prevention strategies implemented at each level of the social ecology. The proposed participants are middle school students, middle school parents, student brand ambassadors (i.e., slightly older youth who promote the communications messages with the target group), educators, school leadership, program implementers, community representives, and local health department representatives in up to four high-risk urban communities.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: The Public Health & Welfare
  

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 49489	08/10/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 65512	10/21/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

IC Title	Form No.	Form Name
Communications Campaign Tracking	35	Communications Campaign Tracking
Local Health Department Capacity and Readiness	36	Local Health Department Capacity and Readiness
Parent Program Capacity and Readiness	37	Parent Program Capacity and Readiness
Community Capacity and Readiness	38	Community Capacity and Readiness
School Leadership Capacity and Readiness Survey	7	School Leadership Capacity and Readiness Survey
Parent Program Fidelity 6th Grade Sessions 1-5	8, 10, 9, 11, 12	Parent Program Fidelity 6th Grade Session 2 ,   Parent Program Fidelity 6th Grade Session 4 ,   Parent Program Fidelity 6th Grade Session 5 ,   Parent Program Fidelity 6th Grade Session 1 ,   Parent Program Fidelity 6th Grade Session 3
Parent Program Fidelity 7th Grade Sessions 1,3,5	11	Parent Program Fidelity 7th Grade Sessions 5
Safe Dates Implementation Survey	12	Safe Dates Implementation Survey
Student Program Fidelity 6th Grade, Sessions 1-6	13, 13, 14, 15, 16, 17, 18	Student Program Fidelity 6th Grade, Sesion 1 ,   Student Program Fidelity 6th Grade, Session 1 ,   Student Program Fidelity 6th Grade, Session 2 ,   Student Program Fidelity 6th Grade, Session 3 ,   Student Program Fidelity 6th Grade, Session 4 ,   Student Program Fidelity 6th Grade, Session 5 ,   Student Program Fidelity 6th Grade, Session 6
Student Program Fidelity 7th, Grade, Session 1-6	19, 20, 21, 22, 23, 24	Student Program Fidelity 7th, Grade, Session 6 ,   Student Program Fidelity 7th, Grade, Session 1 ,   Student Program Fidelity 7th, Grade, Session 2 ,   Student Program Fidelity 7th, Grade, Session 3 ,   Student Program Fidelity 7th, Grade, Session 4 ,   Student Program Fidelity 7th, Grade, Session 5
Student Program Fidelity 8th, Grade, Session 1-10	25, 26, 27, 28, 29, 30, 31, 32, 33, 34	Student Program Fidelity 8th, Grade, Session 1 ,   Student Program Fidelity 8th Grade, Session 2 ,   Student Program Fidelity 8th Grade, Session 3 ,   Student Program Fidelity 8th Grade, Session 4 ,   Student Program Fidelity 8th Grade, Session 5 ,   Student Program Fidelity 8th Grade, Session 6 ,   Student Program Fidelity 8th Grade, Session 7 ,   Student Program Fidelity 8th Grade, Session 8 ,   Student Program Fidelity 8th Grade, Session 9 ,   Student Program Fidelity 8th Grade, Session 10
Student Outcome Survey Baseline	1	Student Outcome Survey - Baseline
Student Outcome Survey Follow-up	2	Student Outcome Survey Follow-up
School Indicators	3	School Indicators
Parent Outcome Survey	4	Parent Outcome Survey
Educator Outcome Survey	5	Educator's Survey
Brand Ambassador Implementation Survey	6	Brand Ambassador Implementation Survey

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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: $1,694,000

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]? 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: 10/31/2011

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