Institutional Awareness and Commitment to Ensuring Safe, Stable, and Nurturing Relationships and Environments for Children

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1010 Institutional Awareness and Commitment Survey (State Health Departments)	Form and Instruction	Modified	Available
SSA - 1-13-14.docx	Supporting Statement A	Uploaded 2014-05-19	Available
ICRC Change Request Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-05-19	Available
SSB - 1-13-14.docx	Supporting Statement B	Uploaded 2014-02-06	Available
Attachment H - Public Comments.docx	Supplementary Document	Uploaded 2014-02-06	Available
Attachment G - IRB - NCIPC Determination.pdf	Supplementary Document	Uploaded 2014-02-06	Available
Attachment B - Published 60-day notice.pdf	Supplementary Document	Uploaded 2014-02-06	Repair queued
Attachment A - Authorizing Legislation.doc	Supplementary Document	Uploaded 2014-02-06	Available
Attachment F - Email Invitation Follow-up.docx	Supplementary Document	Uploaded 2014-02-06	Available
Attachment E- Email Invitation.docx	Supplementary Document	Uploaded 2014-02-06	Available
Attachment C - Survey Screenshots.pdf	Supplementary Document	Uploaded 2014-02-06	Available
Attachment F - Email Invitation Follow-up.docx	Supplementary Document	Uploaded 2014-02-06	Available
Attachment E- Email Invitation.docx	Supplementary Document	Uploaded 2014-02-06	Available
Attachment C - Survey Screenshots.pdf	Supplementary Document	Uploaded 2014-02-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
210318	Institutional Awareness and Commitment Survey (Partner Organizations)	Other-WORD	Unchanged
210317	Institutional Awareness and Commitment Survey (State Health Departments)	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-1010	ICR Reference No: 201405-0920-009
Status: Historical Active	Previous ICR Reference No: 201402-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-14RA
Title: Institutional Awareness and Commitment to Ensuring Safe, Stable, and Nurturing Relationships and Environments for Children
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: 05/28/2014
	Date Received in OIRA: 05/22/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	03/31/2016	03/31/2016
Responses	83	0	83
Time Burden (Hours)	39	0	39
Cost Burden (Dollars)	0	0	0

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Abstract: NCIPC has funded 5 state health departments in FY14 to coordinate and manage existing and new partnerships to promote safe, stable, nurturing relationships and environments for children by raising awareness and commitment, using data to inform decisions, and changing norms, policies, and programs to create a more favorable context for children and families. This data collection will establish the baseline level of state health departments' and partners' awareness and commitment to ensuring safe, stable, and nurturing relationships and environments for children and using data to inform decisions. This information will be collected from the project staff at the health department and from their partners chosen for this initiative once OMB approves this request. State health departments (our grantees for this initiative) have provided several suggestions to improve clarity and flow in the instructions and questions on the survey.

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Authorizing Statute(s): US Code: 42 USC 241 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:
	78 FR 42075	07/15/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 7460	02/07/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Institutional Awareness and Commitment Survey (State Health Departments)	0920-1010, 0920-1010	ICR Attachment D old survey w-tracked changes ,   Attachment D - Survey - New
Institutional Awareness and Commitment Survey (Partner Organizations)

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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	83	83	0	0	0	0
Annual Time Burden (Hours)	39	39	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $11,115

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: 05/22/2014

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