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 DDDD STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	Form	New	Repair queued
Form LLL Student Program Fidelity 8th Grade Session 10	Form and Instruction	New	Available
Form JJJ Student Program Fidelity 8th Grade Session 8	Form and Instruction	New	Available
Form KKK Student Program Fidelity 8th Grade Session 9	Form and Instruction	New	Available
Form III Student Program Fidelity 8th Grade Session 7	Form and Instruction	New	Available
Form HHH Student Program Fidelity 8th Grade Session 6	Form and Instruction	New	Available
Form GGG Student Program Fidelity 8th Grade Session 5	Form and Instruction	New	Available
Form CCC Student Program Fidelity 8th Grade Session 1 (Standard)	Form and Instruction	New	Available
Form EEE Student Program Fidelity 8th Grade Session 3	Form and Instruction	New	Available
Form DDD Student Program Fidelity 8th Grade Session 2	Form and Instruction	New	Available
Form FFF Student Program Fidelity 8th Grade Session 4	Form and Instruction	New	Available
Form BBB Parent curricula implementer focus group guide	Form and Instruction	New	Available
Form PPP Parent Curricula Implementer Consent Form for Focus Group Participation	Form and Instruction	New	Available
Form AAA Student curricula implementer focus group guide	Form and Instruction	New	Available
Form OOO Student Curricula Implementer Consent Form For Focus Group Participation	Form and Instruction	New	Available
Form QQQ Student focus group participant assent form	Form	New	Available
Form ZZ Student participant focus group guide	Form	New	Available
Form SS Local Health Department Capacity and Readiness	Form	New	Repair queued
Form RR Communications Campaign Tracking	Form and Instruction	New	Available
Form QQ Student Program Fidelity 8th Grade Session 10	Form and Instruction	New	Available
Form PP Student Program Fidelity 8th Grade Session 9	Form and Instruction	New	Available
Form OO Student Program Fidelity 8th Grade Session 8	Form and Instruction	New	Available
Form NN Student Program Fidelity 8th Grade Session 7	Form and Instruction	New	Available
Form MM Student Program Fidelity 8th Grade Session 6	Form and Instruction	New	Available
Form LL Student Program Fidelity 8th Grade Session 5	Form and Instruction	New	Available
Form KK Student Program Fidelity 8th Grade Session 4	Form and Instruction	New	Available
Form II Student Program Fidelity 8th Grade Session 2	Form and Instruction	New	Available
Form HH Student Program Fidelity 8th Grade Session 1	Form and Instruction	New	Available
Form JJ Student Program Fidelity 8th Grade Session 3	Form and Instruction	New	Available
Form GG Student Program Fidelity 7th Grade Session 7	Form and Instruction	New	Available
Form FF Student Program Fidelity 7th Grade Session 6	Form and Instruction	New	Available
Form EE Student Program Fidelity 7th Grade Session 5	Form and Instruction	New	Available
Form DD Student Program Fidelity 7th Grade Session 4	Form and Instruction	New	Available
Form CC Student Program Fidelity 7th Grade Session 3	Form and Instruction	New	Available
Form BB Student Program Fidelity 7th Grade Session 2	Form and Instruction	New	Available
Form AA Student Program Fidelity 7th Grade Session 1	Form and Instruction	New	Available
Form Z Student Program Fidelity 6th Grade Session 6	Form and Instruction	New	Available
Form Y Student Program Fidelity 6th Grade Session 5	Form and Instruction	New	Available
Form X Student Program Fidelity 6th Grade Session 4	Form and Instruction	New	Available
Form W Student Program Fidelity 6th Grade Session 3	Form and Instruction	New	Available
Form U Student Program Fidelity 6th Grade Session 1	Form and Instruction	New	Available
Form V Student Program Fidelity 6th Grade Session 2	Form and Instruction	New	Available
Form S Parent Program Fidelity 7th Grade Session 3	Form	New	Available
Form R Parent Program Fidelity 7th Grade Session 1	Form	New	Available
Form T Parent Program Fidelity 7th Grade Session 5	Form	New	Available
Form L Parent Program Fidelity 6th Grade Session 1	Form	New	Available
Form Q Parent Program Fidelity 6th Grade Session 6	Form	New	Available
Form O Parent Program Fidelity 6th Grade Session 5	Form	New	Repair queued
Form N Parent Program Fidelity 6th Grade Session 3	Form	New	Available
Form M Parent Program Fidelity 6th Grade Session 2	Form	New	Available
Form K School Leadership Capacity and Readiness Survey	Form	New	Repair queued
Form J Brand Ambassador Implementation Survey	Form and Instruction	New	Available
Form I Educator Outcome Survey	Form and Instruction	New	Available
Form EEEE Parent Outcome Survey	Form and Instruction	New	Available
Form H Attachment H: Parent Outcome Survey (Baseline)	Form and Instruction	New	Available
Form G Attachment G: School Indicators	Form and Instruction	New	Available
Form E Attachment E: Student Outcome Survey -- Follow-up	Form and Instruction	New	Available
Form F Student Outcome Survey Mid-Term	Form and Instruction	New	Available
Form D Student Outcome Survey -- Baseline	Form and Instruction	New	Available
Attchment FFFF 30 day FRN 02.27.2012 CP17C7.pdf	Supplementary Document	Uploaded 2012-06-27	Available
Attachment C - IRB Approval.docx	Supplementary Document	Uploaded 2012-06-27	Available
Attachment B 60 day FRN 8.10.2011 CPA354.pdf	Supplementary Document	Uploaded 2012-06-27	Available
Attachment A-Authorizing Legislation.docx	Supplementary Document	Uploaded 2012-06-27	Available
Atmt VVV Initial Implementer Focus Group Invitation_11-17-11.docx	Supplementary Document	Uploaded 2012-06-27	Available
Atmt TTT Parent Consent for Student Participation in Focus Group_11-17-11.docx	Supplementary Document	Uploaded 2012-06-27	Available
SSB_11-16-11.docx	Supporting Statement B	Uploaded 2012-02-27	Available
Atmt VVV Initial Implementer Focus Group Invitation_11-17-111.docx	Supplementary Document	Uploaded 2012-03-02	Available
Atmt GGGG Dating Matters FOA.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt CCCC List of participating schools_11-2-11.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt BBBB Script for General Information contact email and voicemail_11-3-11.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt AAAA Follow-up Parent Survey Telephone Script_11-10-11.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt ZZZ Follow-up Educator Survey Email_11-10-11.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt YYY Follow-up Parent Survey Reminder_11-10-11.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt XXX Parent Participant Alternative Contact Form_11-3-11.doc	Supplementary Document	Uploaded 2012-02-28	Available
Atmt WWW Initial Parent Web Survey Invitation Cover Letter_11-10-11.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt UUU Initial Educator Web Survey Invitiation Cover Letter_11-10-11.docx	Supplementary Document	Uploaded 2012-02-28	Available
Atmt MMM LHD Capacity Readiness Screenshots.pdf	Supplementary Document	Uploaded 2012-02-28	Available
Atmt NNN School leadership Capacity Readiness Screenshots.pdf	Supplementary Document	Uploaded 2012-02-27	Available
Atmt NNN - Cover Page.docx	Supplementary Document	Uploaded 2012-02-27	Available
Atmt RRR Screen Shots Educator Survey_11-22-11 BT.doc	Supplementary Document	Uploaded 2012-02-27	Available
Atmt SSS Screen shots parent survey_11-22-11 BT.doc	Supplementary Document	Uploaded 2012-02-27	Repair queued
Atmt VV Parent Program Participant Consent Form.docx	Supplementary Document	Uploaded 2012-02-27	Available
SSA 2-16-2012.docx	Supporting Statement A	Uploaded 2012-02-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201415	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	Form	New	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 10
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 8
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 9
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 7
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 6
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 5
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 1 (Standard)
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 3
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 2
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	New	Student Program Fidelity 8th Grade Session 4
201413	Parent Curricula Implementer Focus Group Guide	Form and Instruction	New	Parent curricula implementer focus group guide
201413	Parent Curricula Implementer Focus Group Guide	Form and Instruction	New	Parent Curricula Implementer Consent Form for Focus Group Participation
201412	Student Curricula Implementer Focus Group Guide	Form and Instruction	New	Student curricula implementer focus group guide
201412	Student Curricula Implementer Focus Group Guide	Form and Instruction	New	Student Curricula Implementer Consent Form For Focus Group Participation
201411	Student Participant Focus Group	Form	New	Student focus group participant assent form
201411	Student Participant Focus Group	Form	New	Student participant focus group guide
201410	Local Health Department Capacity and Readiness	Form	New	Local Health Department Capacity and Readiness
201409	Communications Campaign Tracking	Form and Instruction	New	Communications Campaign Tracking
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 10
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 9
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 8
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 7
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 6
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 5
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 4
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 2
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 1
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	New	Student Program Fidelity 8th Grade Session 3
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	New	Student Program Fidelity 7th Grade Session 7
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	New	Student Program Fidelity 7th Grade Session 6
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	New	Student Program Fidelity 7th Grade Session 5
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	New	Student Program Fidelity 7th Grade Session 4
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	New	Student Program Fidelity 7th Grade Session 3
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	New	Student Program Fidelity 7th Grade Session 2
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	New	Student Program Fidelity 7th Grade Session 1
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	New	Student Program Fidelity 6th Grade Session 6
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	New	Student Program Fidelity 6th Grade Session 5
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	New	Student Program Fidelity 6th Grade Session 4
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	New	Student Program Fidelity 6th Grade Session 3
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	New	Student Program Fidelity 6th Grade Session 1
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	New	Student Program Fidelity 6th Grade Session 2
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	New	Parent Program Fidelity 7th Grade Session 3
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	New	Parent Program Fidelity 7th Grade Session 1
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	New	Parent Program Fidelity 7th Grade Session 5
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	New	Parent Program Fidelity 6th Grade Session 1
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	New	Parent Program Fidelity 6th Grade Session 6
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	New	Parent Program Fidelity 6th Grade Session 5
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	New	Parent Program Fidelity 6th Grade Session 3
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	New	Parent Program Fidelity 6th Grade Session 2
201403	School Leadership Capacity and Readiness Survey	Form	New	School Leadership Capacity and Readiness Survey
201402	Brand Ambassador Implementation Survey	Form and Instruction	New	Brand Ambassador Implementation Survey
201401	Educator Outcome Survey	Form and Instruction	New	Educator Outcome Survey
201400	Parent Outcome Follow-up Survey	Form and Instruction	New	Parent Outcome Survey
201399	Parent Outcome Baseline Survey	Form and Instruction	New	Attachment H: Parent Outcome Survey (Baseline)
201398	School Indicators	Form and Instruction	New	Attachment G: School Indicators
201397	Student Outcome Survey Follow-up	Form and Instruction	New	Attachment E: Student Outcome Survey -- Follow-up
201396	School Outcome Survey Mid-Term	Form and Instruction	New	Student Outcome Survey Mid-Term
201395	Student Outcome Survey Baseline	Form and Instruction	New	Student Outcome Survey -- Baseline

ICR Details

OMB Control No: 0920-0941	ICR Reference No: 201203-0920-002
Status: Historical Active	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: Approved with change	Conclusion Date: 06/28/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/02/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	74,101	0	0
Time Burden (Hours)	44,978	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 representatives, and local health department representatives in up to four high-risk urban communities.

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Authorizing Statute(s): None

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:
	77 FR 11539	02/27/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 21

table that charts list of burden

IC Title	Form No.	Form Name
Brand Ambassador Implementation Survey	J	Brand Ambassador Implementation Survey
Communications Campaign Tracking	RR	Communications Campaign Tracking
Educator Outcome Survey	I	Educator Outcome Survey
Local Health Department Capacity and Readiness	SS	Local Health Department Capacity and Readiness
Parent Curricula Implementer Focus Group Guide	PPP, BBB	Parent Curricula Implementer Consent Form for Focus Group Participation ,   Parent curricula implementer focus group guide
Parent Outcome Baseline Survey	H	Attachment H: Parent Outcome Survey (Baseline)
Parent Outcome Follow-up Survey	EEEE	Parent Outcome Survey
Parent Program Fidelity 6th Grade Sessions 1-6	M, N, O, Q, L	Parent Program Fidelity 6th Grade Session 2 ,   Parent Program Fidelity 6th Grade Session 3 ,   Parent Program Fidelity 6th Grade Session 5 ,   Parent Program Fidelity 6th Grade Session 6 ,   Parent Program Fidelity 6th Grade Session 1
Parent Program Fidelity 7th Grade Sessions 1, 3, 5	T, R, S	Parent Program Fidelity 7th Grade Session 5 ,   Parent Program Fidelity 7th Grade Session 1 ,   Parent Program Fidelity 7th Grade Session 3
STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	DDDD	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM
School Indicators	G	Attachment G: School Indicators
School Leadership Capacity and Readiness Survey	K	School Leadership Capacity and Readiness Survey
School Outcome Survey Mid-Term	F	Student Outcome Survey Mid-Term
Student Curricula Implementer Focus Group Guide	OOO, AAA	Student Curricula Implementer Consent Form For Focus Group Participation ,   Student curricula implementer focus group guide
Student Outcome Survey Baseline	D	Student Outcome Survey -- Baseline
Student Outcome Survey Follow-up	E	Attachment E: Student Outcome Survey -- Follow-up
Student Participant Focus Group	ZZ, QQQ	Student participant focus group guide ,   Student focus group participant assent form
Student Program Fidelity 6th Grade Sessions 1 - 6	Z, U, V, W, X, Y	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 Sessions 1 - 7	AA, BB, CC, DD, EE, FF, GG	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 7th Grade Session 6 ,   Student Program Fidelity 7th Grade Session 7
Student Program Fidelity 8th Grade Sessions 1 - 10	HH, II, JJ, KK, LL, MM, NN, OO, PP, QQ	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 Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	GGG, HHH, III, KKK, JJJ, LLL, DDD, EEE, CCC, FFF	Student Program Fidelity 8th Grade Session 2 ,   Student Program Fidelity 8th Grade Session 3 ,   Student Program Fidelity 8th Grade Session 1 (Standard) ,   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 9 ,   Student Program Fidelity 8th Grade Session 8 ,   Student Program Fidelity 8th Grade Session 10

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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	74,101	0	0	74,101	0	0
Annual Time Burden (Hours)	44,978	0	0	44,978	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 Information Collection Request

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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: 03/02/2012

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