Screenshots for State Education Agencies

Promoting Adolescent Health through School-based HIV/STD Prevention

Att 8a SEA Screens 4abc

State Education Agency Safe and Supportive Environment Measures

OMB: 0920-1049

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Attachment 8a: Screenshots from PERS

For Attachments 4a, b &c

State Education Agency (SEA) Screenshots



The data will be collected from funded agencies via the Program Evaluation and Reporting System (PERS). Screenshots for the State Education Agency (SEA) questionnaires are provided below in the order presented in the Burden Table (Table A.12-1) in Supporting Statement A. The questionnaires for the Local Education Agencies (LEA) and Non-governmental organizations (NGO) are included in Attachment 8b and 8c, respectively.

The questionnaires in PERS cover the following topics: exemplary sexual health education (ESHE); sexual health services (SHS); and safe and supportive environments (SSE). The burden statement and OMB form approval information are reflected on the initial page of each group of screenshots that correspond to the questionnaires. To view the measures and the list of questions in text format, see Attachments 4a, b &c.





State Education Agency (SEA) Screenshots



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







“Promoting Adolescent Health through School-Based HIV/STD Prevention”


Att. 4c


SEA ESHE Items






Public reporting burden of this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)









Picture 10



Picture 13

Picture 16



Picture 19



Picture 1

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent.

Part A of screenshot. This screen is scrolling enabled.Picture 67

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 70

Part A of screenshot. This screen is scrolling enabled.Picture 1

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 7

Part A of screenshot. This screen is scrolling enabled.Picture 10

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 13

Part A of screenshot. This screen is scrolling enabled.Picture 16

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 19

Part A of screenshot. This screen is scrolling enabled.Picture 22

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 25

Part A of screenshot. This screen is scrolling enabled.Picture 28

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 31

Part A of screenshot. This screen is scrolling enabled.Picture 34

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 37

Part A of screenshot. This screen is scrolling enabled.Picture 40

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 43

Part C of screenshot. This screen is scrolling enabled.Picture 46

Part A of screenshot. This screen is scrolling enabled.Picture 49

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 52

Part C of screenshot. This screen is scrolling enabled.Picture 55



Part A of screenshot. This screen is scrolling enabled.Picture 121

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 124



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







“Promoting Adolescent Health through School-Based HIV/STD Prevention”


Att. 4b


SEA SHS Items





Public reporting burden of this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Picture 22



Picture 25



Picture 28

Part A of screenshot. This screen is scrolling enabled.Picture 58

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 61

Part A of screenshot. This screen is scrolling enabled.Picture 64

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 67

Part A of screenshot. This screen is scrolling enabled.Picture 70

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 73

Part A of screenshot. This screen is scrolling enabled.Picture 76

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 79

Part A of screenshot. This screen is scrolling enabled.Picture 82

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 85

Part A of screenshot. This screen is scrolling enabled.Picture 127

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 130



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







“Promoting Adolescent Health through School-Based HIV/STD Prevention”


Att. 4a


SEA SSE Items






Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)







Picture 37

Picture 40



Picture 43

Part A of screenshot. This screen is scrolling enabled.Picture 88

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 91

Part A of screenshot. This screen is scrolling enabled.Picture 94

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 97

Part A of screenshot. This screen is scrolling enabled.Picture 100

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 103

Part A of screenshot. This screen is scrolling enabled.Picture 106

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 109

Part A of screenshot. This screen is scrolling enabled.Picture 115

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 118

Part A of screenshot. This screen is scrolling enabled.Picture 133

*Note: The highlighted part in the screenshot will be tailored to the Priority District Name of interest for each SEA respondent. The left-hand side of the screenshot shows where the potential Priority Districts will be listed. Each can be selected to answer this question.

Part B of screenshot. This screen is scrolling enabled.Picture 136




Instruction Slides

Log-in screen

Picture 1

Screen that appears after logging in with username and passwordPicture 4

Main page. Questionnaires located in “Evaluation Measures Reporting” tab.

Picture 7

Main screen with links to questionnaires. ESHE, SHS, and SSE questions are organized in the three categories for ease of data entry.




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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorRebecca Smartis
File Modified0000-00-00
File Created2021-01-26
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