Targeted Surveillance and Biometric Studies for Enhanced Evaluation of CTGs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Adult Targeted Surveillance Survey telephone screener- Spanish	Form	Modified	Available
Adult Targeted Surveillance Survey - telephone screener	Form	Modified	Available
Youth Survey - Spanish	Form	Modified	Available
Youth Survey	Form	Modified	Available
Spanish Survey Recruitment Screener for Youth	Form	Removed	Repair queued
Survey Recruitment Screener for Youth	Form	Removed	Available
Youth Activity Diary - Spanish	Form	Modified	Available
Youth Activity Diary	Form	Modified	Available
Youth Biometric Measures - Spanish	Form	Modified	Repair queued
Youth Biometric Measures	Form	Modified	Available
Youth Activity Diary - Spanish	Form	Modified	Available
Youth Activity Diary	Form	Modified	Available
Caregiver Survey - Spanish	Form	Modified	Available
Caregiver Survey	Form	Modified	Available
Spanish Caregiver Screener	Form	Removed	Available
Caregiver Screener	Form	Removed	Available
Adult Activity Diary - Spanish	Form	Modified	Available
Adult Activity Diary	Form	Modified	Available
Adult Biometric Measures - Spanish	Form	Modified	Repair queued
Adult Biometric Measures	Form	Modified	Available
Adult Targeted Surveillance Survey - phone interview Spanish	Form	Modified	Available
Adult Targeted Surveillance Survey - phone interview	Form	Modified	Available
Spanish Biometric Screener in-person	Form	Removed	Available
Biometric Screener in-person	Form	Removed	Repair queued
Adult Biometric Measures Recruitment Screener - Spanish	Form	Modified	Available
Adult Biometric Measures Recruitment Screener	Form	Modified	Available
Adult Biometric Measures Recruitment Screener-Spanish	Form	Modified	Available
Adult Biometric Measures Recruitment Screener	Form	Modified	Available
Survey Booklet - Spanish	Form	Modified	Available
Survey Booklet	Form	Modified	Available
0920-12IG_Cover Memo_June 2013 Revision_Final.doc	Supplementary Document	Uploaded 2013-08-06	Available
0920-12IG Part B_08062013.docx	Supporting Statement B	Uploaded 2013-08-06	Available
Att 12C_AdultBioMeasures_ItemSources.pdf	Supplementary Document	Uploaded 2013-04-22	Available
Att 13D-S_AccelReminder_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 13D_Accelerometry Reminder.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11F-S_Enhanced_Script_Adults_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11F_Enhanced_Script_Adults.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11E-S_Enhanced_Script_Caregivers(3-11)_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11E_Enhanced_Script_Caregivers(3-11).docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11D-S_Enhanced_Script_Youth(12-17)_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11D_Enhanced_Script_Youth(12-17).docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11C-S_Enhanced_Script_Parents(12-17)_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11C_Enhanced_Script_Parents(12-17).docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 11B_ATSS_ReminderPostcard.doc	Supplementary Document	Uploaded 2013-04-22	Available
Att 11A4-S_Letter_SecondMailing_Paper_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A4_Letter_SecondMailing_Paper.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A3-S_Letter_Paper_AfterPhoneAttempt_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A3_Letter_Paper_AfterPhoneAttempt.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A-S_LeadLetter_Standard_Phone_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A2-S_Letter_FirstMailing_Paper_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A1-S_LeadLetter_Enhanced_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A1_LeadLetter_Enhanced.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A2_Letter_FirstMailing_Paper.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 11A_LeadLetter_Standard_Phone.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 8B-S_Letter_ATSS_Gift_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 8B_Letter_ATSS_Gift.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 8A-S_ATSS_GiftForm_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 8A_ATSS_GiftForm.docx	Supplementary Document	Uploaded 2013-08-06	Repair queued
Att 6E-S_Enhanced_ParentalPermission_SP.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 6E_Enhanced_ParentalPermission.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 6D-S_Enhanced_Consent_SP.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 6D_Enhanced_Consent.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 6C-S_Enhanced_YouthAssent_SP.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 6C_Enhanced_YouthAssent.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 6B-S_Standard_Consent(Phone)_SP.docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 6B_Standard_Consent(Phone).docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 6A-S_Standard_Consent(Paper)_SP.docx	Supplementary Document	Uploaded 2013-08-06	Repair queued
Att 6A_Standard_Consent(Paper).docx	Supplementary Document	Uploaded 2013-08-06	Available
Att 5_DataSources.doc	Supplementary Document	Uploaded 2013-04-18	Available
Att 4C_ListofCTGAwardees.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 4B_CTGEvaluationPlan.doc	Supplementary Document	Uploaded 2013-04-18	Available
Att 4A_StrategicDirections.docx	Supplementary Document	Uploaded 2013-04-18	Available
Att 3B_IRBApproval_Enhanced.pdf	Supplementary Document	Uploaded 2013-04-18	Available
Att 3A_IRBApproval_Standard.pdf	Supplementary Document	Uploaded 2013-04-18	Available
Att 2_60-dayFRN.pdf	Supplementary Document	Uploaded 2013-04-18	Available
Att 1B_ACASection4201.doc	Supplementary Document	Uploaded 2013-04-18	Available
Att 1A_PHSA.pdf	Supplementary Document	Uploaded 2013-04-18	Repair queued
Att 13A-S_AccelInstructions_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 13A_AccelInstructions.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 13A-S_AccelInstructions_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 13A_AccelInstructions.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 13A-S_AccelInstructions_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 13A_AccelInstructions.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 10B-S_EnhancedInvitation_forATSS_Paper_SP.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 10B_EnhancedInvitation_forATSS_Paper.docx	Supplementary Document	Uploaded 2013-04-22	Available
Att 7B-S_ATSS_FAQGuide_SP.doc	Supplementary Document	Uploaded 2013-04-22	Available
Att 7B_ATSS_FAQGuide.doc	Supplementary Document	Uploaded 2013-04-22	Available
0920-12IG Part A_08062013.docx	Supporting Statement A	Uploaded 2013-08-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203638	Adult Targeted Surveillance Survey - screener	Form	Modified	Adult Targeted Surveillance Survey telephone screener- Spanish
203638	Adult Targeted Surveillance Survey - screener	Form	Modified	Adult Targeted Surveillance Survey - telephone screener
203637	Youth Survey	Form	Modified	Youth Survey - Spanish
203637	Youth Survey	Form	Modified	Youth Survey
203636	Youth Survey Recruitment Screener for Youth	Form	Removed	Spanish Survey Recruitment Screener for Youth
203636	Youth Survey Recruitment Screener for Youth	Form	Removed	Survey Recruitment Screener for Youth
203635	Youth Activity Diary - completed by youth	Form	Modified	Youth Activity Diary - Spanish
203635	Youth Activity Diary - completed by youth	Form	Modified	Youth Activity Diary
203634	Youth Biometric Measures	Form	Modified	Youth Biometric Measures - Spanish
203634	Youth Biometric Measures	Form	Modified	Youth Biometric Measures
203633	Youth Activity Diary - completed by caregiver	Form	Modified	Youth Activity Diary - Spanish
203633	Youth Activity Diary - completed by caregiver	Form	Modified	Youth Activity Diary
203632	Caregiver Survey	Form	Modified	Caregiver Survey - Spanish
203632	Caregiver Survey	Form	Modified	Caregiver Survey
203631	Caregiver Survey Recruitment Screener	Form	Removed	Spanish Caregiver Screener
203631	Caregiver Survey Recruitment Screener	Form	Removed	Caregiver Screener
203630	Adult Activity Diary	Form	Modified	Adult Activity Diary - Spanish
203630	Adult Activity Diary	Form	Modified	Adult Activity Diary
203629	Adult Biometric Measures	Form	Modified	Adult Biometric Measures - Spanish
203629	Adult Biometric Measures	Form	Modified	Adult Biometric Measures
203628	Adult Targeted Surveillance Survey - Telephone Interview	Form	Modified	Adult Targeted Surveillance Survey - phone interview Spanish
203628	Adult Targeted Surveillance Survey - Telephone Interview	Form	Modified	Adult Targeted Surveillance Survey - phone interview
203627	Adult Biometric Measures Recruitment Screener (In-person)	Form	Removed	Spanish Biometric Screener in-person
203627	Adult Biometric Measures Recruitment Screener (In-person)	Form	Removed	Biometric Screener in-person
203626	Adult Biometric Measures - screener	Form	Modified	Adult Biometric Measures Recruitment Screener - Spanish
203626	Adult Biometric Measures - screener	Form	Modified	Adult Biometric Measures Recruitment Screener
203626	Adult Biometric Measures - screener	Form	Modified	Adult Biometric Measures Recruitment Screener-Spanish
203626	Adult Biometric Measures - screener	Form	Modified	Adult Biometric Measures Recruitment Screener
203625	Adult Targeted Surveillance Survey - paper	Form	Modified	Survey Booklet - Spanish
203625	Adult Targeted Surveillance Survey - paper	Form	Modified	Survey Booklet

ICR Details

OMB Control No: 0920-0977	ICR Reference No: 201305-0920-002
Status: Historical Active	Previous ICR Reference No: 201208-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 19291
Title: Targeted Surveillance and Biometric Studies for Enhanced Evaluation of CTGs
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: 08/16/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/07/2013
Terms of Clearance: Approved consistent with the understanding that there are inherent limitations in the design of the evaluations for drawing quantitative conclusions about the effectiveness of different types of programs. It is understood that this study will be used as part of a larger literature about the effectiveness of such interventions. CDC will continue to collaborate with NIH and other federal partners on studies with similar outcomes of interest.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved
Responses	40,164	0	0
Time Burden (Hours)	11,360	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC plans to conduct a study to collect key outcomes required by the ACA in up to 20 selected areas funded through the Community Transformation Grants Program. This is a population-based household assessment of persons 3 years of age and older who live in 20 CTG areas that are implementing interventions. Adults will be asked to complete an Adult Targeted Surveillance Survey as part of a standard protocol. A sample of househoulds from 8 of the areas will be selected to participate in an enhanced protocol that involves an in-home visit to collect biometric measures. All participants will be administered a questionnaire to assess core ACA outcomes.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4201 Name of Law: Patient Protection and ACA PPHF
   US Code: 42 USC 301 Name of Law: PHSA
  

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 23263	04/18/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47073	08/07/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

table that charts list of burden

IC Title	Form No.	Form Name
Adult Activity Diary	none, none	Adult Activity Diary ,   Adult Activity Diary - Spanish
Adult Biometric Measures	none, none	Adult Biometric Measures ,   Adult Biometric Measures - Spanish
Adult Biometric Measures - screener	none, none, none, none	Adult Biometric Measures Recruitment Screener ,   Adult Biometric Measures Recruitment Screener-Spanish ,   Adult Biometric Measures Recruitment Screener ,   Adult Biometric Measures Recruitment Screener - Spanish
Adult Biometric Measures Recruitment Screener (In-person)	none, none	Biometric Screener in-person ,   Spanish Biometric Screener in-person
Adult Targeted Surveillance Survey - Telephone Interview	none, none	Adult Targeted Surveillance Survey - phone interview ,   Adult Targeted Surveillance Survey - phone interview Spanish
Adult Targeted Surveillance Survey - paper	none, none	Survey Booklet ,   Survey Booklet - Spanish
Adult Targeted Surveillance Survey - screener	none, none	Adult Targeted Surveillance Survey - telephone screener ,   Adult Targeted Surveillance Survey telephone screener- Spanish
Caregiver Survey	none, none	Caregiver Survey ,   Caregiver Survey - Spanish
Caregiver Survey Recruitment Screener	none, none	Caregiver Screener ,   Spanish Caregiver Screener
Youth Activity Diary - completed by caregiver	none, none	Youth Activity Diary ,   Youth Activity Diary - Spanish
Youth Activity Diary - completed by youth	none, none	Youth Activity Diary ,   Youth Activity Diary - Spanish
Youth Biometric Measures	none, none	Youth Biometric Measures ,   Youth Biometric Measures - Spanish
Youth Survey	none, none	Youth Survey ,   Youth Survey - Spanish
Youth Survey Recruitment Screener for Youth	none, none	Survey Recruitment Screener for Youth ,   Spanish Survey Recruitment Screener for Youth

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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	40,164	0	0	40,164	0	0
Annual Time Burden (Hours)	11,360	0	0	11,360	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 to support evaluation of ACA activities. Republication of the 30 day waived by OMB as the scope and methodology has not changed from the previous submission.

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Annual Cost to Federal Government: $5,044,216

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? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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: 04/23/2013

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