Promoting Adolescent Health through School-based HIV/STD Prevention

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
NGO Exemplary Sexual Health Education Measures	Form	New	Available
NGO Safe and Supportive Environment Measures	Form	New	Repair queued
NGO Sexual Health Services Measures	Form	New	Available
Screenshots for NGO	Form	New	Repair queued
LEA Exemplary Sexual Health Education Measures	Form	New	Available
LEA Sexual Health Services Measures	Form	New	Available
LEA Safe and Supportive Environment Measures	Form	New	Available
Screenshots for Local Education Agencies	Form	New	Available
SEA Exemplary Sexual Health Education Measures	Form	New	Available
SEA Sexual Health Services Measures	Form	New	Repair queued
Screenshots for State Education Agencies	Form	New	Available
SEA Safe and Supportive Environment Measures	Form	New	Available
Att 11 Eval Framework.pdf	Supplementary Document	Uploaded 2015-01-22	Available
SS-A_OMB Clean Version.docx	Supporting Statement A	Uploaded 2015-01-22	Available
Att 10 Analysis of Alternatives.doc	Supplementary Document	Uploaded 2014-09-04	Available
Att 9c SSE Rationale.pdf	Supplementary Document	Uploaded 2014-09-04	Available
Att 9b SHS Rationale.pdf	Supplementary Document	Uploaded 2014-09-04	Available
Att 9a ESHE Rationale.pdf	Supplementary Document	Uploaded 2014-09-04	Available
Att 7 Funded Agencies Providing Feedback.docx	Supplementary Document	Uploaded 2014-09-04	Available
Att 6 List of Funded Agencies.docx	Supplementary Document	Uploaded 2014-09-04	Repair queued
Att 2 60 Day FRN.pdf	Supplementary Document	Uploaded 2014-09-04	Available
Att 1 Public Health Service Act Legislation.pdf	Supplementary Document	Uploaded 2014-09-04	Available
SSB.docx	Supporting Statement B	Uploaded 2015-01-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212973	NGO Exemplary Sexual Health Education Measures	Form	New	NGO Exemplary Sexual Health Education Measures
212972	NGO Safe and Supportive Environment Measures	Form	New	NGO Safe and Supportive Environment Measures
212971	NGO Sexual Health Services Measures	Form	New	NGO Sexual Health Services Measures
212971	NGO Sexual Health Services Measures	Form	New	Screenshots for NGO
212970	Local Education Agency Exemplary Sexual Health Education Measures	Form	New	LEA Exemplary Sexual Health Education Measures
212969	Local Education Agency Sexual Health Services Measures	Form	New	LEA Sexual Health Services Measures
212968	Local Education Agency Safe and Supportive Environment Measures	Form	New	LEA Safe and Supportive Environment Measures
212968	Local Education Agency Safe and Supportive Environment Measures	Form	New	Screenshots for Local Education Agencies
212967	State Education Agency Exemplary Sexual Health Education Measures	Form	New	SEA Exemplary Sexual Health Education Measures
212966	State Education Agency Sexual Health Services Measures	Form	New	SEA Sexual Health Services Measures
212965	State Education Agency Safe and Supportive Environment Measures	Form	New	Screenshots for State Education Agencies
212965	State Education Agency Safe and Supportive Environment Measures	Form	New	SEA Safe and Supportive Environment Measures

ICR Details

OMB Control No: 0920-1049	ICR Reference No: 201409-0920-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 14VU
Title: Promoting Adolescent Health through School-based HIV/STD Prevention
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: 02/03/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/23/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2018	36 Months From Approved
Responses	228	0	0
Time Burden (Hours)	820	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: We request a 3-year approval for data collection using a Web-based program evaluation and monitoring system to organize, plan, and track PS13-1308 funded agency activities conducted to meet the performance and process measures established by the CDC Division of Adolescent and School Health (DASH). The system will provide access to data and reports for DASH and its funded agencies (state and local education agencies and non-governmental organizations), which allows areas for improvement to be identified and addressed. The questionnaires include performance and process measures to be used for program monitoring, evaluation, and quality improvement for HIV/STD prevention activities.

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Authorizing Statute(s): US Code: 42 USC 241 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:
	79 FR 24437	04/30/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 53427	09/09/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Local Education Agency Exemplary Sexual Health Education Measures	none	LEA Exemplary Sexual Health Education Measures
Local Education Agency Safe and Supportive Environment Measures	none, none	Screenshots for Local Education Agencies ,   LEA Safe and Supportive Environment Measures
Local Education Agency Sexual Health Services Measures	none	LEA Sexual Health Services Measures
NGO Exemplary Sexual Health Education Measures	none	NGO Exemplary Sexual Health Education Measures
NGO Safe and Supportive Environment Measures	none	NGO Safe and Supportive Environment Measures
NGO Sexual Health Services Measures	none, none	Screenshots for NGO ,   NGO Sexual Health Services Measures
State Education Agency Exemplary Sexual Health Education Measures	none	SEA Exemplary Sexual Health Education Measures
State Education Agency Safe and Supportive Environment Measures	none, none	SEA Safe and Supportive Environment Measures ,   Screenshots for State Education Agencies
State Education Agency Sexual Health Services Measures	none	SEA Sexual Health Services Measures

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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	228	0	0	228	0	0
Annual Time Burden (Hours)	820	0	0	820	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: $498,851

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: 09/23/2014

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