Fetal Alcohol Spectrum Disorders Regional Training Centers

Forms and Documents

Document Name	Status
Southeast Follow-up Form	New
Southeast Post-test Form	New
Southeast Pre-test Form	New
Midwest Utilization of Curriculum Pre-test and Follow-up Form	New
Midwest Modified Index Collaboration Pre-test and Follow-up Form	New
Midwest Continuing Education Follow-up Form	New
Midwest Continuing Education Post-test Form	New
Midwest Continuing Education Pre-test Form	New
Midwest Event Evaluation Form	New
Midwest Academic Knowledge Post-test and Follow-up Form	New
Midwest Academic Knowledge Pre-test Form	New
Great Lakes Trainers Activity Reporting Form	New
Great Lakes Trainers Harvard Minute Feedback Form	New
Great Lakes Advisory Committee Key Informant Interview Form	New
Great Lakes Regional State Partners Key Informant Interview Form	New
Great Lakes Trainers Key Informant Interview Form	New
Great Lakes Physicians Clinical Experience B Form	New
Great Lakes Physicians Clinical Experience A Form	New
Great Lakes Healthcare Providers Comprehensive Follow-up Form	New
Great Lakes Healthcare Providers Comprehensive Post-test Form	New
Great Lakes Healthcare Providers Comprehensive Pre-test Form	New
Great Lakes Healthcare Providers ID and Treatment Follow-up Form	New
Great Lakes Healthcare Providers ID and Treatment Post-test Form	New
Great Lakes Healthcare Providers ID and Treatment Pre-test Form	New
Great Lakes Health Care Providers SBI Follow-up Form	New
Great Lakes Health Care Providers SBI Post-test Form	New
Great Lakes Health Care Providers SBI Pre-test Form	New
Great Lakes Medical and Allied Health Care Providers Follow-up Form	New
Great Lakes Medical and Allied Health Care Providers Post-test Form	New
Great Lakes Medical and Allied Health Care Providers Pre-test Form	New
Frontier Practitioner Online Follow-up Form	New
Frontier Practitioner Online Post-test Form	New
Frontier Practitioner Online Pre-test Form	New
Frontier Academic Faculty and Students Online Follow-up Form	New
Frontier Academic Faculty and Students Online Post-test Form	New
Frontier Academic Faculty and Students Online Pre-test Form	New
Frontier Training of Trainers Follow-up Form	New
Frontier Training of Trainers Post-test Form	New
Frontier Training of Trainers Pre-test Form	New
Frontier Allied Health Practioner Follow-up Form	New
Frontier Allied Health Practioner Post-test Form	New
Frontier Allied Health Practioner Pre-test Form	New
Frontier Social Work Follow-up Form	New
Frontier Social Work Post-test Form	New
Frontier Social Work Pre-test Form	New
Frontier Nursing Follow-up Form	New
Frontier Nursing Post-test Form	New
Frontier Nursing Pre-test Form	New
Arctic Classroom and Special Event Post-test Form	New
Arctic Online III Pre- and Post-test Form	New
Arctic Online II Pre- and Post-test Form	New
Arctic Online I Pre- and Post-test Form	New
Arctic Train the Trainer Follow-up Form	New
Arctic Train the Trainer Post-test Form	New
Arctic Train the Trainer Pre-test Form	New
Arctic Intro to FASD Follow-up Form	New
Arctic Intro to FASD Post-test Form	New
Arctic Intro to FASD Pre-test Form	New
Arctic FASD 201 Follow-up Form	New
Arctic FASD 201 Post-test Form	New
Arctic FASD 201 Pre-test Form	New
Arctic Foundations Follow-up Form	New
Arctic Foundations Post-test Form	New
Arctic Foundations Pre-test Form	New
OMB Part B document RJP edits (0828)_revised 1-17-2013.docx Supporting Statement B	2013-02-01
60DAY_FASD_RTC.pdf Supplementary Document	2012-09-13
Attachment A Legal authority.docx Supplementary Document	2012-09-13
F8_Midwest FASD Regional Training Center Utilization of FAS-FASD Curr, Pre-evaluation.doc Supplementary Document	2012-09-19
F7_Midwest FASD Regional Training Center Modified Index of Interdisciplinary Collab, Pre-Test.docx Supplementary Document	2012-09-19
F2_Midwest FASD Regional Training Center Knowledge Post-Test.doc Supplementary Document	2012-09-19
E11_Great Lakes FASD RegionalTraining Center FASD Comprehensive_1.docx Supplementary Document	2012-09-19
E11_Great Lakes FASD RegionalTraining Center FASD Comprehensive_1.docx Supplementary Document	2012-09-19
E10_Great Lakes FASD RegionalTraining Center FASD Comprehensive.docx Supplementary Document	2012-09-19
E9_Great Lakes FASD RegionalTraining Center Identification and.docx Supplementary Document	2012-09-19
E8_Great Lakes FASD RegionalTraining Center Identification and.docx Supplementary Document	2012-09-19
E7_Great Lakes FASD RegionalTraining Center Identification and.docx Supplementary Document	2012-09-19
E6_Great Lakes FASD RegionalTraining Center Screening and Brief.docx Supplementary Document	2012-09-13
E5_Great Lakes FASD RegionalTraining Center Screening and Brief.docx Supplementary Document	2012-09-13
E4_Great Lakes FASD RegionalTraining Center Screening and Brief.docx Supplementary Document	2012-09-13
E3_Great Lakes FASD RTC Foundations of FASD 6moFU.docx Supplementary Document	2012-09-13
E2_Great Lakes FASD RTC Foundations of FASD_post.docx Supplementary Document	2012-09-13
E1_Great Lakes FASD RTC Foundations of FASD Pre.docx Supplementary Document	2012-09-13
Section A Justification FASD Regional Training Centers Evaluation (08282012)_revised 1-17-2013.docx Supporting Statement A	2013-02-01

IC Document Collections

IC ID	Document Title	Status
204269	Southeast Follow-up Form	New
204268	Southeast Post-test Form	New
204267	Southeast Pre-test Form	New
204266	Midwest Utilization of Curriculum Pre-test and Follow-up Form	New
204265	Midwest Modified Index Collaboration Pre-test and Follow-up Form	New
204264	Midwest Continuing Education Follow-up Form	New
204263	Midwest Continuing Education Post-test Form	New
204262	Midwest Continuing Education Pre-test Form	New
204261	Midwest Event Evaluation Form	New
204260	Midwest Academic Knowledge Post-test and Follow-up Form	New
204259	Midwest Academic Knowledge Pre-test Form	New
204258	Great Lakes Trainers Activity Reporting Form	New
204257	Great Lakes Trainers Harvard Minute Feedback Form	New
204256	Great Lakes Advisory Committee Key Informant Interview Form	New
204255	Great Lakes Regional State Partners Key Informant Interview Form	New
204254	Great Lakes Trainers Key Informant Interview Form	New
204253	Great Lakes Physicians Clinical Experience B Form	New
204252	Great Lakes Physicians Clinical Experience A Form	New
204251	Great Lakes Healthcare Providers Comprehensive Follow-up Form	New
204250	Great Lakes Healthcare Providers Comprehensive Post-test Form	New
204249	Great Lakes Healthcare Providers Comprehensive Pre-test Form	New
204248	Great Lakes Healthcare Providers ID and Treatment Follow-up Form	New
204247	Great Lakes Healthcare Providers ID and Treatment Post-test Form	New
204246	Great Lakes Healthcare Providers ID and Treatment Pre-test Form	New
204245	Great Lakes Health Care Providers SBI Follow-up Form	New
204244	Great Lakes Health Care Providers SBI Post-test Form	New
204243	Great Lakes Health Care Providers SBI Pre-test Form	New
204242	Great Lakes Medical and Allied Health Care Providers Follow-up Form	New
204241	Great Lakes Medical and Allied Health Care Providers Post-test Form	New
204240	Great Lakes Medical and Allied Health Care Providers Pre-test Form	New
204239	Frontier Practitioner Online Follow-up Form	New
204238	Frontier Practitioner Online Post-test Form	New
204237	Frontier Practitioner Online Pre-test Form	New
204236	Frontier Academic Faculty and Students Online Follow-up Form	New
204235	Frontier Academic Faculty and Students Online Post-test Form	New
204234	Frontier Academic Faculty and Students Online Pre-test Form	New
204233	Frontier Training of Trainers Follow-up Form	New
204232	Frontier Training of Trainers Post-test Form	New
204231	Frontier Training of Trainers Pre-test Form	New
204230	Frontier Allied Health Practioner Follow-up Form	New
204229	Frontier Allied Health Practioner Post-test Form	New
204228	Frontier Allied Health Practioner Pre-test Form	New
204227	Frontier Social Work Follow-up Form	New
204226	Frontier Social Work Post-test Form	New
204225	Frontier Social Work Pre-test Form	New
204224	Frontier Nursing Follow-up Form	New
204223	Frontier Nursing Post-test Form	New
204222	Frontier Nursing Pre-test Form	New
204221	Arctic Classroom and Special Event Post-test Form	New
204220	Arctic Online III Pre- and Post-test Form	New
204219	Arctic Online II Pre- and Post-test Form	New
204218	Arctic Online I Pre- and Post-test Form	New
204217	Arctic Train the Trainer Follow-up Form	New
204216	Arctic Train the Trainer Post-test Form	New
204215	Arctic Train the Trainer Pre-test Form	New
204214	Arctic Intro to FASD Follow-up Form	New
204213	Arctic Intro to FASD Post-test Form	New
204212	Arctic Intro to FASD Pre-test Form	New
204211	Arctic FASD 201 Follow-up Form	New
204210	Arctic FASD 201 Post-test Form	New
204209	Arctic FASD 201 Pre-test Form	New
204208	Arctic Foundations Follow-up Form	New
204207	Arctic Foundations Post-test Form	New
204206	Arctic Foundations Pre-test Form	New

ICR Details

OMB Control No: 0920-0954	ICR Reference No: 201209-0920-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Fetal Alcohol Spectrum Disorders Regional Training Centers
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: 02/04/2013
	Date Received in OIRA: 09/26/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	24 Months From Approved
Responses	15,640	0	0
Time Burden (Hours)	2,654	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: NCBDDD will collect program evaluation data from participants of trainings for medical and allied health students and practitioners regarding fetal alcohol spectrum disorders (FASDs) conducted by the FASD Regional Training Centers through a cooperative agreement with CDC. Guidelines for the diagnosis of FAS and other negative birth outcomes resulting from prenatal exposure to alcohol have been developed and incorporated into the training curricula, to help students and professionals with the prevention, identification, and treatment of FAS and related disorders.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

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:
	77 FR 27067	05/05/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58843	09/24/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 64

IC Title	Form No.	Form Name
Arctic FASD 201 Follow-up	none	FASD 201 Follow-up
Arctic Intro to FASD Pre-test	none	Intro to FASD Pre-test
Arctic Intro to FASD Post-test	none	Intro to FASD Post-test
Arctic Intro to FASD Follow-up	none	Intro to FASD Follow-up
Arctic Train the Trainer Pre-test	none	Train the Trainer Pre-test
Arctic Train the Trainer Post-test	none	Train the Trainer Post-test
Arctic Train the Trainer Follow-up	none	Train the Trainer Follow-up
Arctic Online I Pre- and Post-test	none	Online I Pre- and Post-test
Arctic Online II Pre- and Post-test	none	Online II Pre- and Post-test
Arctic Online III Pre- and Post-test	none	Online III Pre- and Post-test
Arctic Classroom and Special Event Post-test	none	Classroom and Special Event Post-test
Frontier Nursing Pre-test	none	Nursing Pre-test
Frontier Allied Health Practioner Post-test	none	Allied Health Post-test
Frontier Allied Health Practioner Follow-up	none	Allied Health Follow-up
Frontier Training of Trainers Pre-test	none	Training of Trainers Pre-test
Frontier Training of Trainers Post-test	none	Training of Trainers Post-test
Frontier Training of Trainers Follow-up	none	Training of Trainers Follow-up
Frontier Academic Faculty and Students Online Pre-test	none	Academic Pre-test
Frontier Academic Faculty and Students Online Post-test	none	Academic Post-test
Frontier Academic Faculty and Students Online Follow-up	none	Academic Follow-up
Frontier Practitioner Online Pre-test	none	Practitioner Online Pre-test
Frontier Practitioner Online Post-test	none	Practitioner Online Post-test
Frontier Practitioner Online Follow-up	none	Practitioner Online Follow-up
Great Lakes Health Care Providers SBI Post-test	none	SBI Post-test
Great Lakes Health Care Providers SBI Follow-up	none	SBI Follow-up
Great Lakes Healthcare Providers ID and Treatment Pre-test	none	ID and Treatment Pre-test
Great Lakes Healthcare Providers ID and Treatment Post-test	none	Great Lakes ID and Treatment Post-test
Great Lakes Healthcare Providers ID and Treatment Follow-up	none	Great Lakes ID and Treatment Follow-up
Great Lakes Healthcare Providers Comprehensive Pre-test	none	Great Lakes Comprehensive Pre-test
Great Lakes Healthcare Providers Comprehensive Post-test	none	Great Lakes Comprehensive Post-test
Great Lakes Healthcare Providers Comprehensive Follow-up	none	Great Lakes Comprehensive Follow-up
Great Lakes Physicians Clinical Experience A	none	Great Lakes Physicians Clinical Experience A
Great Lakes Physicians Clinical Experience B	none	Great Lakes Physicians Clinical Experience B
Great Lakes Trainers Key Informant Interview	none	Great Lakes Trainers Key Informant Interview
Great Lakes Regional State Partners Key Informant Interview	none	Great Lakes Regional State Partners Key Informant Interview
Great Lakes Advisory Committee Key Informant Interview	none	Great Lakes Advisory Committee Key Informant Interview
Great Lakes Trainers Harvard Minute Feedback	none	Great Lakes Trainers Harvard Minute Feedback
Great Lakes Trainers Activity Reporting	none	Great Lakes Trainers Activity Reporting
Midwest Academic Knowledge Pre-test	none	Midwest Academic Knowledge Pre-test
Frontier Nursing Post-test	none	Nursing Post-test
Frontier Nursing Follow-up	none	Nursing Follow-up
Frontier Social Work Pre-test	none	Social Work Pre-test
Frontier Social Work Post-test	none	Social Work Post-test
Frontier Social Work Follow-up	none	Social Work Follow-up
Frontier Allied Health Practioner Pre-test	none	Allied Health Pre-test
Great Lakes Medical and Allied Health Care Providers Post-test	none	Foundations Online Post-test
Great Lakes Medical and Allied Health Care Providers Follow-up	none	Foundations Online Follow-up
Great Lakes Health Care Providers SBI Pre-test	none	SBI Pre-test
Midwest Academic Knowledge Post-test and Follow-up	none	Midwest Academic Knowledge Post-test and Follow-up
Midwest Event Evaluation	none	Midwest Event Evaluation
Midwest Continuing Education Pre-test	none	Midwest Continuing Education Pre-test
Midwest Continuing Education Post-test	none	Midwest Continuing Education Post-test
Midwest Continuing Education Follow-up	none	Midwest Continuing Education Follow-up
Midwest Modified Index Collaboration Pre-test and Follow-up	none	Midwest Modified Index Collaboration Pre-test and Follow-up
Midwest Utilization of Curriculum Pre-test and Follow-up	none	Midwest Utilization of Curriculum Pre-test and Follow-up
Southeast Pre-test	none	Southeast Pre-test
Southeast Post-test	none	Southeast Post-test
Southeast Follow-up	none	Southeast Follow-up
Great Lakes Medical and Allied Health Care Providers Pre-test	none	Foundations Online Pre-test
Arctic Foundations Pre-test	none	Foundations Pre-test
Arctic Foundations Post-test	none	Foundations Post-test
Arctic Foundations Follow-up	none	Found ations Follow-up
Arctic FASD 201 Pre-test	none	FASD 201 Pre-test
Arctic FASD 201 Post-test	none	FASD 201 Post-test

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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	15,640	0	0	15,640	0	0
Annual Time Burden (Hours)	2,654	0	0	2,654	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 ICR.

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Annual Cost to Federal Government: $927,463

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: 09/26/2012

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