Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

Forms and Documents

Document Name	Status
STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM Form	Modified
Form III Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard) Form and Instruction	Modified
Form PPP Parent Curricula Implementer Focus Group Guide Form and Instruction	Modified
Form OOO Student Curricula Implementer Focus Group Guide Form and Instruction	Modified
Local Health Department Capacity and Readiness Form	Modified
Communications Campaign Tracking Form and Instruction	Modified
Form HH Student Program Fidelity 8th Grade Sessions 1 - 10 Form and Instruction	Modified
Form AA Student Program Fidelity 7th Grade Sessions 1 - 7 Form and Instruction	Modified
Form V Student Program Fidelity 6th Grade Sessions 1 - 6 Form and Instruction	Modified
Form T Parent Program Fidelity 7th Grade Sessions 1, 3, 5 Form	Modified
Form M Parent Program Fidelity 6th Grade Sessions 1-6 Form	Modified
School Leadership Capacity and Readiness Survey Form and Instruction	Modified
Brand Ambassador Implementation Survey Form and Instruction	Modified
Educator Outcome Survey Baseline Form and Instruction	Modified
Form 6 Parent Outcome Follow-up Survey Form and Instruction	Modified
Parent Outcome Baseline Survey Form and Instruction	Modified
Form 4 School Indicators Form and Instruction	Modified
Form 3 Student Outcome Survey Follow-up Form and Instruction	Modified
Form 2 Student Outcome Survey Mid-Term Form and Instruction	Modified
Student Outcome Survey Baseline Form and Instruction	Modified
SSB_OMB 0920-0941 - Final clean 81712.docx Supporting Statement B	2012-08-17
OMB 0920-0941 change request August 2012.doc Justification for No Material/Nonsubstantive Change	2012-08-17
Atmt RRR Screen Shots Educator Survey_11-22-11 BT.doc Supplementary Document	2012-02-27
Atmt MMM LHD Capacity Readiness Screenshots.pdf Supplementary Document	2012-02-28
Atmt NNN School leadership Capacity Readiness Screenshots.pdf Supplementary Document	2012-02-27
Atmt NNN - Cover Page.docx Supplementary Document	2012-02-27
Atmt RRR Screen Shots Educator Survey_11-22-11 BT.doc Supplementary Document	2012-02-27
Atmt SSS Screen shots parent survey_11-22-11 BT.doc Supplementary Document	2012-02-27
Atmt VV Parent Program Participant Consent Form.docx Supplementary Document	2012-02-27
SSA - OMB 0920-0941 - Final clean.docx Supporting Statement A	2012-08-17

IC Document Collections

IC ID	Document Title	Status
201415	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM Form	Modified
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard) Form and Instruction	Modified
201413	Parent Curricula Implementer Focus Group Guide Form and Instruction	Modified
201412	Student Curricula Implementer Focus Group Guide Form and Instruction	Modified
201411	Student Participant Focus Group Instruction	Modified
201410	Local Health Department Capacity and Readiness Form	Modified
201409	Communications Campaign Tracking Form and Instruction	Modified
201408	Student Program Fidelity 8th Grade Sessions 1 - 10 Form and Instruction	Modified
201407	Student Program Fidelity 7th Grade Sessions 1 - 7 Form and Instruction	Modified
201406	Student Program Fidelity 6th Grade Sessions 1 - 6 Form and Instruction	Modified
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5 Form	Modified
201404	Parent Program Fidelity 6th Grade Sessions 1-6 Form	Modified
201403	School Leadership Capacity and Readiness Survey Form and Instruction	Modified
201402	Brand Ambassador Implementation Survey Form and Instruction	Modified
201401	Educator Outcome Survey Baseline Form and Instruction	Modified
201400	Parent Outcome Follow-up Survey Form and Instruction	Modified
201399	Parent Outcome Baseline Survey Form and Instruction	Modified
201398	School Indicators Form and Instruction	Modified
201397	Student Outcome Survey Follow-up Form and Instruction	Modified
201396	Student Outcome Survey Mid-Term Form and Instruction	Modified
201395	Student Outcome Survey Baseline Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0941	ICR Reference No: 201208-0920-005
Status: Historical Active	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: Approved without change	Conclusion Date: 08/17/2012
	Date Received in OIRA: 08/17/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	06/30/2015	06/30/2015
Responses	59,521	0	74,101
Time Burden (Hours)	35,099	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: 21

IC Title	Form No.	Form Name
Student Outcome Survey Mid-Term	2	Student Outcome Survey Mid-Term
Student Outcome Survey Baseline	None	Student Outcome Survey Baseline
Student Outcome Survey Follow-up	3	Attachment E: Student Outcome Survey -- Follow-up
School Indicators	4	Attachment G: School Indicators
Parent Outcome Baseline Survey	None	Parent Outcome Baseline Survey
Parent Outcome Follow-up Survey	6	Parent Outcome Survey
Educator Outcome Survey Baseline	None	Educator Outcome Survey (Baseline)
Brand Ambassador Implementation Survey	None	Brand Ambassador Implementation Survey
School Leadership Capacity and Readiness Survey	None	School Leadership Capacity and Readiness 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 2
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 Fidelity 6th Grade Sessions 1 - 6	V, U, W, X, Y, Z	Student Program Fidelity 6th Grade Session 2 ,   Student Program Fidelity 6th Grade Session 1 ,   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
Communications Campaign Tracking	None	Communications Campaign Tracking Form
Local Health Department Capacity and Readiness	None	Local Health Department Capacity and Readiness
Student Participant Focus Group
Student Curricula Implementer Focus Group Guide	OOO	Student Curricula Implementer Consent Form For Focus Group Participation
Parent Curricula Implementer Focus Group Guide	PPP	Parent Curricula Implementer Consent Form for Focus Group Participation
Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	DDD, EEE, CCC, FFF, GGG, HHH, III, KKK, JJJ, LLL	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 ,   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 MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	None	Master Trainer TA Tracking Form

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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	59,521	74,101	0	-14,580	0	0
Annual Time Burden (Hours)	35,099	44,978	0	-9,879	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: . The burden has decreased slightly, due to: 1) re-estimating the student sample size based on actual enrollment of participating schools (previously an average enrollment was used); 2) re-calculating burden estimates for 23 standard schools and 21 comprehensive schools (previously 22 standard schools and 22 comprehensive schools) due to a few school closings during the planning year and subsequent recruitment and re-randomization of replacement schools; and, 3) re-estimating the number of implementer respondents based on the sites actual plans for hiring implementers (previously estimated based on anticipated number of implementers).

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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: 08/17/2012

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