Community-based Organization (CBO) Monitoring and Evaluation Project of RESPECT (CMEP-RESPECT)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
180-day Follow-up Interview	Form	Modified	Available
90-day follow-up Interview	Form	Modified	Available
Form 3 Baseline Interview	Form and Instruction	Removed	Available
Form 1 Eligibility--Screener	Form and Instruction	Removed	Available
SS-Part A RESPECT rev aug 26.doc	Supporting Statement A	Uploaded 2014-08-28	Available
att2 60 Day FRN.pdf	Supplementary Document	Uploaded 2014-06-05	Available
att1_PHSAsect301.pdf	Supplementary Document	Uploaded 2014-06-05	Available
SS_Part B.doc	Supporting Statement B	Uploaded 2014-06-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198830	180-day Follow-up Interview--Grantee	Instruction	Modified
198829	180-day Follow-up Interview	Form	Modified
198828	90-day follow-up Interview--Grantee	Instruction	Modified
198827	90-day follow-up Interview	Form	Modified
198826	Baseline Interview--Grantee	Other-Screen Shot	Removed
198825	Baseline Interview	Form and Instruction	Removed
198824	Eligibility--Screener--Grantee	Other-Screen Shot	Removed
198823	Eligibility--Screener	Form and Instruction	Removed

ICR Details

OMB Control No: 0920-0895	ICR Reference No: 201406-0920-004
Status: Historical Active	Previous ICR Reference No: 201108-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Community-based Organization (CBO) Monitoring and Evaluation Project of RESPECT (CMEP-RESPECT)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/29/2014
	Date Received in OIRA: 06/18/2014
Terms of Clearance: This extension allows each site to continue using only the incentive levels that they already used for 90- and 180-day follow ups in their area. This approval should not be interpreted as a precedent for differential incentives.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	12 Months From Approved	08/31/2014
Responses	736	0	1,732
Time Burden (Hours)	200	0	358
Cost Burden (Dollars)	0	0	0

---

Abstract: This project serves to monitor changes in client's self-reported HIV risk behaviors and attitudes after participating in the Effective Behavioral Intervention (EBI) Respect as delivered by CDC-funded CBOs and to assess the fidelity of the delivery of Respect at CBOs. CDC funded CMEP-RESPECT for 5 years. From April 2012 through April 2014 baseline suverys were conducted with 871 participants; 90 day follow-ups were completed with 576 participants and 180 day follow-ups with 484 participants. CDC requests an additional one year of approval to complete follow-up surveys for participants completing the intervention before August 2014.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 14253	03/13/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 33195	06/10/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Eligibility--Screener	1	Eligibility Screener
Eligibility--Screener--Grantee
Baseline Interview--Grantee
90-day follow-up Interview	none, none	90 day Follow-up Survey ,   90 day Follow-up Screenshots
90-day follow-up Interview--Grantee
180-day Follow-up Interview	none, none	180 day follow-up survey ,   180 day follow up survey screenshots
180-day Follow-up Interview--Grantee
Baseline Interview	3	Baseline Interview

---

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	736	1,732	0	-996	0	0
Annual Time Burden (Hours)	200	358	0	-158	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden is reduced because the screener and baseline surveys have been completed and the program requests a one year extension to complete the follow-up surveys and data submission to complete the project.

---

Annual Cost to Federal Government: $755,325

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

---

Common Form ICR:  No

---

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: 06/18/2014

---