Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Attachment F Educator Outcome Survey (Follow-up)	Form and Instruction	New	Available
Form DDDD STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	Form	Modified	Available
Attachments CCC-LLL Safe Dates Sessions 1-10	Form and Instruction	Modified	Available
Form LLL Student Program Fidelity 8th Grade Session 10	Form and Instruction	Modified	Available
Form JJJ Student Program Fidelity 8th Grade Session 8	Form and Instruction	Modified	Available
Form KKK Student Program Fidelity 8th Grade Session 9	Form and Instruction	Modified	Available
Form III Student Program Fidelity 8th Grade Session 7	Form and Instruction	Modified	Available
Form HHH Student Program Fidelity 8th Grade Session 6	Form and Instruction	Modified	Available
Form GGG Student Program Fidelity 8th Grade Session 5	Form and Instruction	Modified	Available
Form FFF Student Program Fidelity 8th Grade Session 4	Form and Instruction	Modified	Available
Form CCC Student Program Fidelity 8th Grade Session 1 (Standard)	Form and Instruction	Modified	Available
Form EEE Student Program Fidelity 8th Grade Session 3	Form and Instruction	Modified	Available
Form DDD Student Program Fidelity 8th Grade Session 2	Form and Instruction	Modified	Repair queued
Form PPP Parent Curricula Implementer Consent Form for Focus Group Participation	Form and Instruction	Modified	Available
Form OOO Student Curricula Implementer Consent Form For Focus Group Participation	Form and Instruction	Modified	Available
Form SS Local Health Department Capacity and Readiness	Form	Modified	Available
Form RR Communications Campaign Tracking	Form and Instruction	Modified	Available
Attachments HH-QQ Student Program Fidelity Sessions 1-10	Form and Instruction	Modified	Repair queued
Form QQ Student Program Fidelity 8th Grade Session 10	Form and Instruction	Modified	Repair queued
Form PP Student Program Fidelity 8th Grade Session 9	Form and Instruction	Modified	Available
Form OO Student Program Fidelity 8th Grade Session 8	Form and Instruction	Modified	Available
Form NN Student Program Fidelity 8th Grade Session 7	Form and Instruction	Modified	Available
Form MM Student Program Fidelity 8th Grade Session 6	Form and Instruction	Modified	Repair queued
Form LL Student Program Fidelity 8th Grade Session 5	Form and Instruction	Modified	Available
Form KK Student Program Fidelity 8th Grade Session 4	Form and Instruction	Modified	Available
Form JJ Student Program Fidelity 8th Grade Session 3	Form and Instruction	Modified	Available
Form II Student Program Fidelity 8th Grade Session 2	Form and Instruction	Modified	Available
Form HH Student Program Fidelity 8th Grade Session 1	Form and Instruction	Modified	Available
Attachments AA-GG Student Program Fidelity 7th Grade Sessions 1-7	Form and Instruction	Modified	Available
Form GG Student Program Fidelity 7th Grade Session 7	Form and Instruction	Modified	Available
Form FF Student Program Fidelity 7th Grade Session 6	Form and Instruction	Modified	Available
Form EE Student Program Fidelity 7th Grade Session 5	Form and Instruction	Modified	Available
Form DD Student Program Fidelity 7th Grade Session 4	Form and Instruction	Modified	Repair queued
Form CC Student Program Fidelity 7th Grade Session 3	Form and Instruction	Modified	Available
Form BB Student Program Fidelity 7th Grade Session 2	Form and Instruction	Modified	Repair queued
Form AA Student Program Fidelity 7th Grade Session 1	Form and Instruction	Modified	Available
Form Z Student Program Fidelity 6th Grade Session 6	Form and Instruction	Modified	Available
Form Y Student Program Fidelity 6th Grade Session 5	Form and Instruction	Modified	Available
Form X Student Program Fidelity 6th Grade Session 4	Form and Instruction	Modified	Available
Form W Student Program Fidelity 6th Grade Session 3	Form and Instruction	Modified	Available
Form V Student Program Fidelity 6th Grade Session 2	Form and Instruction	Modified	Available
Form U Student Program Fidelity 6th Grade Session 1	Form and Instruction	Modified	Repair queued
Attachments R-T Parent Program Fidelity Sessions 1,3,5	Form	Modified	Repair queued
Form S Parent Program Fidelity 7th Grade Session 3	Form	Modified	Available
Form R Parent Program Fidelity 7th Grade Session 1	Form	Modified	Available
Form T Parent Program Fidelity 7th Grade Session 5	Form	Modified	Available
Attachments L-Q Parent Program Fidelity 6th Grade Sessions 1-6	Form	Modified	Available
Form L Parent Program Fidelity 6th Grade Session 2	Form	Modified	Available
Form Q Parent Program Fidelity 6th Grade Session 6	Form	Modified	Available
Form O Parent Program Fidelity 6th Grade Session 5	Form	Modified	Available
Form N Parent Program Fidelity 6th Grade Session 3	Form	Modified	Available
Form M Parent Program Fidelity 6th Grade Session 2	Form	Modified	Available
School Leadership Capacity and Readiness Survey	Form	Modified	Available
Form 9 School Leadership Capacity and Readiness Survey	Form	Modified	Available
Form 8 Brand Ambassador Implementation Survey	Form and Instruction	Modified	Repair queued
Form no form number Educator Outcome Survey Baseline	Form and Instruction	Modified	Available
Form 7 Educator Outcome Survey	Form and Instruction	Modified	Available
Form 6 Parent Outcome Survey	Form and Instruction	Modified	Repair queued
Form no form number Parent Outcome Survey Baseline	Form and Instruction	Modified	Available
Form 5 Attachment H: Parent Outcome Survey (Baseline)	Form and Instruction	Modified	Available
Form 4 Attachment G: School Indicators	Form and Instruction	Modified	Available
Form 3 Attachment E: Student Outcome Survey -- Follow-up	Form and Instruction	Modified	Available
Form 2 Student Outcome Survey Mid-Term	Form and Instruction	Modified	Repair queued
Form no number Student Baseline Outcome Survey	Form and Instruction	Modified	Available
Form 1 Student Outcome Survey -- Baseline	Form and Instruction	Modified	Available
Change request Memo 7-23-2012.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-07-23	Available
Atmt RRR Screen Shots Educator Survey_11-22-11 BT.doc	Supplementary Document	Uploaded 2012-02-27	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	Available
Atmt VV Parent Program Participant Consent Form.docx	Supplementary Document	Uploaded 2012-02-27	Available
SSA - OMB 0920-0941 - Final clean.docx	Supporting Statement A	Uploaded 2012-07-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203501	Educator Outcome Survey (Follow-up)	Form and Instruction	New	Attachment F Educator Outcome Survey (Follow-up)
201415	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	Form	Modified	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Attachments CCC-LLL Safe Dates Sessions 1-10
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 10
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 8
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 9
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 7
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 6
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 5
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 4
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 1 (Standard)
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 3
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 2
201413	Parent Curricula Implementer Focus Group Guide	Form and Instruction	Modified	Parent Curricula Implementer Consent Form for Focus Group Participation
201413	Parent Curricula Implementer Focus Group Guide	Other-Focus Group Guide	Modified
201412	Student Curricula Implementer Focus Group Guide	Form and Instruction	Modified	Student Curricula Implementer Consent Form For Focus Group Participation
201412	Student Curricula Implementer Focus Group Guide	Other-Focus Group Guide	Modified
201411	Student Participant Focus Group	Instruction	Modified
201410	Local Health Department Capacity and Readiness	Form	Modified	Local Health Department Capacity and Readiness
201409	Communications Campaign Tracking	Form and Instruction	Modified	Communications Campaign Tracking
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Attachments HH-QQ Student Program Fidelity Sessions 1-10
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 10
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 9
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 8
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 7
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 6
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 5
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 4
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 3
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 2
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Modified	Student Program Fidelity 8th Grade Session 1
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Attachments AA-GG Student Program Fidelity 7th Grade Sessions 1-7
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Student Program Fidelity 7th Grade Session 7
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Student Program Fidelity 7th Grade Session 6
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Student Program Fidelity 7th Grade Session 5
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Student Program Fidelity 7th Grade Session 4
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Student Program Fidelity 7th Grade Session 3
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Student Program Fidelity 7th Grade Session 2
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Modified	Student Program Fidelity 7th Grade Session 1
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Modified	Student Program Fidelity 6th Grade Session 6
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Modified	Student Program Fidelity 6th Grade Session 5
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Modified	Student Program Fidelity 6th Grade Session 4
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Modified	Student Program Fidelity 6th Grade Session 3
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Modified	Student Program Fidelity 6th Grade Session 2
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Modified	Student Program Fidelity 6th Grade Session 1
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	Modified	Attachments R-T Parent Program Fidelity Sessions 1,3,5
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	Modified	Parent Program Fidelity 7th Grade Session 3
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	Modified	Parent Program Fidelity 7th Grade Session 1
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	Modified	Parent Program Fidelity 7th Grade Session 5
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Modified	Attachments L-Q Parent Program Fidelity 6th Grade Sessions 1-6
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Modified	Parent Program Fidelity 6th Grade Session 2
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Modified	Parent Program Fidelity 6th Grade Session 6
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Modified	Parent Program Fidelity 6th Grade Session 5
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Modified	Parent Program Fidelity 6th Grade Session 3
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Modified	Parent Program Fidelity 6th Grade Session 2
201403	School Leadership Capacity and Readiness Survey	Form	Modified	School Leadership Capacity and Readiness Survey
201403	School Leadership Capacity and Readiness Survey	Form	Modified	School Leadership Capacity and Readiness Survey
201402	Brand Ambassador Implementation Survey	Form and Instruction	Modified	Brand Ambassador Implementation Survey
201401	Educator Outcome Survey Baseline	Form and Instruction	Modified	Educator Outcome Survey Baseline
201401	Educator Outcome Survey Baseline	Form and Instruction	Modified	Educator Outcome Survey
201400	Parent Outcome Follow-up Survey	Form and Instruction	Modified	Parent Outcome Survey
201399	Parent Outcome Baseline Survey	Form and Instruction	Modified	Parent Outcome Survey Baseline
201399	Parent Outcome Baseline Survey	Form and Instruction	Modified	Attachment H: Parent Outcome Survey (Baseline)
201398	School Indicators	Form and Instruction	Modified	Attachment G: School Indicators
201397	Student Outcome Survey Follow-up	Form and Instruction	Modified	Attachment E: Student Outcome Survey -- Follow-up
201396	School Outcome Survey Mid-Term	Form and Instruction	Modified	Student Outcome Survey Mid-Term
201395	Student Outcome Survey Baseline	Form and Instruction	Modified	Student Baseline Outcome Survey
201395	Student Outcome Survey Baseline	Form and Instruction	Modified	Student Outcome Survey -- Baseline

ICR Details

OMB Control No: 0920-0941	ICR Reference No: 201207-0920-010
Status: Historical Inactive	Previous ICR Reference No: 201203-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships
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: Improperly submitted and continue	Conclusion Date: 08/06/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/27/2012
Terms of Clearance: Proposed changes should be submitted as a revision to the existing approval.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	06/30/2015	06/30/2015
Responses	74,101	0	74,101
Time Burden (Hours)	44,978	0	44,978
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

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 22

table that charts list of burden

IC Title	Form No.	Form Name
Brand Ambassador Implementation Survey	8	Brand Ambassador Implementation Survey
Communications Campaign Tracking	RR	Communications Campaign Tracking
Educator Outcome Survey (Follow-up)	None	Attachment F Educator Outcome Survey (Follow-up)
Educator Outcome Survey Baseline	7, no form number	Educator Outcome Survey ,   Educator Outcome Survey Baseline
Local Health Department Capacity and Readiness	SS	Local Health Department Capacity and Readiness
Parent Curricula Implementer Focus Group Guide	PPP	Parent Curricula Implementer Consent Form for Focus Group Participation
Parent Outcome Baseline Survey	5, no form number	Attachment H: Parent Outcome Survey (Baseline) ,   Parent Outcome Survey Baseline
Parent Outcome Follow-up Survey	6	Parent Outcome Survey
Parent Program Fidelity 6th Grade Sessions 1-6	M, N, O, Q, L, None	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 2 ,   Attachments L-Q Parent Program Fidelity 6th Grade Sessions 1-6
Parent Program Fidelity 7th Grade Sessions 1, 3, 5	T, R, S, None	Parent Program Fidelity 7th Grade Session 5 ,   Parent Program Fidelity 7th Grade Session 1 ,   Parent Program Fidelity 7th Grade Session 3 ,   Attachments R-T Parent Program Fidelity Sessions 1,3,5
STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	DDDD	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM
School Indicators	4	Attachment G: School Indicators
School Leadership Capacity and Readiness Survey	9, None	School Leadership Capacity and Readiness Survey ,   School Leadership Capacity and Readiness Survey
School Outcome Survey Mid-Term	2	Student Outcome Survey Mid-Term
Student Curricula Implementer Focus Group Guide	OOO	Student Curricula Implementer Consent Form For Focus Group Participation
Student Outcome Survey Baseline	1, no number	Student Outcome Survey -- Baseline ,   Student Baseline Outcome Survey
Student Outcome Survey Follow-up	3	Attachment E: Student Outcome Survey -- Follow-up
Student Participant Focus Group
Student Program Fidelity 6th Grade Sessions 1 - 6	U, V, W, X, Y, Z	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, None	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 ,   Attachments AA-GG Student Program Fidelity 7th Grade Sessions 1-7
Student Program Fidelity 8th Grade Sessions 1 - 10	HH, II, JJ, KK, LL, MM, NN, OO, PP, QQ, None	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 ,   Attachments HH-QQ Student Program Fidelity Sessions 1-10
Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	DDD, EEE, CCC, FFF, GGG, HHH, III, KKK, JJJ, LLL, None	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 ,   Attachments CCC-LLL Safe Dates Sessions 1-10

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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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This nonmaterial, non-substantive change request reflects changes to clarify procedures and reduce redundancies in data collection instruments. This change results in a streamlined and improved flow in readability of information collection instruments and instructions in order to improve participant comprehension. Outcome Evaluation Surveys: Attachments D, H, I - The three baseline outcome evaluation instruments were streamlined in order to reduce redundancy. The overall aim and content of the instruments are unchanged. See the justification Memo.

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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: 07/27/2012

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