Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

Forms and Documents

Document Name	Status
7th Grade Curricula Parent Satisfaction Questionnaire Form and Instruction	Modified
6th Grade Curricula Parent Satisfaction Questionnaire Form and Instruction	Modified
Parent Program Manager TA Tracking Form Form	Modified
Community Capacity/Readiness Assessment Form and Instruction	Modified
Educator Outcome Evaluation Survey-Follow-up Form and Instruction	Modified
STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM Form	Modified
Form DDD 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
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
Student Outcome Survey Follow-up - High School Form	Modified
Student Outcome Survey Baseline Form and Instruction	Modified
SSB - 9-4-2013.docx Supporting Statement B	2013-09-05
Change Request Memo.doc Justification for No Material/Nonsubstantive Change	2013-09-05
Atmt NNN - Cover Page.docx Supplementary Document	2012-02-27
Atmt VV Parent Program Participant Consent Form.docx Supplementary Document	2012-02-27
SSA - 9-4-2013.docx Supporting Statement A	2013-09-05

IC Document Collections

IC ID	Document Title	Status
206026	7th Grade Curricula Parent Satisfaction Questionnaire Form and Instruction	Modified
206025	6th Grade Curricula Parent Satisfaction Questionnaire Form and Instruction	Modified
206024	Parent Program Manager TA Tracking Form Form	Modified
206023	Communications Focus Groups Instruction	Modified
206022	Community Capacity/Readiness Assessment Form and Instruction	Modified
206021	Educator Outcome Evaluation Survey-Follow-up Form and Instruction	Modified
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 - High School Form	Modified
201395	Student Outcome Survey Baseline Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0941	ICR Reference No: 201309-0920-005
Status: Historical Active	Previous ICR Reference No: 201303-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 20485
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: 09/12/2013
	Date Received in OIRA: 09/11/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	05/31/2016	05/31/2016
Responses	52,897	0	52,897
Time Burden (Hours)	28,814	0	27,923
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. Changes requested are to amend the student follow-up survey with questions that will be relevant to participating youth as they matriculate into high school.

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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

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 26

IC Title	Form No.	Form Name
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 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
STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	None	Master Trainer TA Tracking Form
Educator Outcome Evaluation Survey-Follow-up	none	Educator Outcome Survey Follow-up
Community Capacity/Readiness Assessment	none	Community Capacity/Readiness Assessment
Communications Focus Groups
Parent Program Manager TA Tracking Form	none	Parent Program Manager (PPM) Technical Assistance Tracking form
6th Grade Curricula Parent Satisfaction Questionnaire	none	Parents Matter! for Dating Matters: Participant Satisfaction Questionnaire
7th Grade Curricula Parent Satisfaction Questionnaire	none	Dating Matters for Parents: Participant Satisfaction Questionnaire
Student Outcome Survey Baseline	None	Student Outcome Survey Baseline
Student Outcome Survey Follow-up - High School	none	Student Outcome Survey
School Indicators	4	Attachment G: School Indicators
Parent Outcome Baseline Survey	none	Parent/Guardian Survey
Parent Outcome Follow-up Survey	None, none	Parent Outcome Survey Follow-up ,   Parent/Guardian Consent Form
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

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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	52,897	52,897	0	0	0	0
Annual Time Burden (Hours)	28,814	27,923	0	891	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 request for change involves a slight increase in burden only.

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Annual Cost to Federal Government: $1,719,000

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: 09/11/2013

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