Assessing Community-Based Organizations' Partnerships with Schools for the Prevention of HIV/STDs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Web-basedHWC Assessment	Form and Instruction	New	Available
Web-based CBO Assessment	Form and Instruction	New	Available
Att 13 Example Data Analysis Table Shells.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 12 IRB Approval Letter.pdf	Supplementary Document	Uploaded 2015-04-10	Available
Att 11 Public Comment.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 10 List of Consultants.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 9 Web-based Informed Consent Form for HWC Questionnaire.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 8 Web-based Informed Consent Form for CBO Questionnaire.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 4 DASH YMSM HWC Assessment.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 7 Introductory Email.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 3 DASH YMSM CBO Assessment.docx	Supplementary Document	Uploaded 2015-04-10	Available
Att 2 60-day FRN.pdf	Supplementary Document	Uploaded 2015-04-10	Available
Att 1 Public Health Service Act Legislation.pdf	Supplementary Document	Uploaded 2015-04-10	Available
SSB 31AUG2015.docx	Supporting Statement B	Uploaded 2015-09-08	Available
SSA 31AUG2015.docx	Supporting Statement A	Uploaded 2015-09-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216051	Web-basedHWC Assessment	Form and Instruction	New
216050	Web-based CBO Assessment	Form and Instruction	New

ICR Details

OMB Control No: 0920-1084	ICR Reference No: 201504-0920-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15KX
Title: Assessing Community-Based Organizations' Partnerships with Schools for the Prevention of HIV/STDs
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: 09/11/2015
	Date Received in OIRA: 04/28/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	36 Months From Approved
Responses	60	0	0
Time Burden (Hours)	60	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CDC requests a 3-year OMB approval to conduct a new information collection (IC) entitled, "Assessing Community-Based Organizations' Partnerships with Schools for the Prevention of HIV/STDs." The IC uses two versions of a self-administered web-based questionnaire --the Community-based organization (CBO) Assessment Questionnaire and the Health and/or Wellness Center (HWC) Assessment Questionnaire --to conduct an in-depth assessment with staff from CBOs and HWCs, which include school wellness centers and school-based health centers. The assessment will ask about partnerships and HIV and STD prevention efforts that are taking place in conjunction with the three local education agencies (LEAs) funded by the CDC, Division of Adolescent and School Health (DASH) under strategy 4 (School-Centered HIV/STD Prevention for Young MSM) of PS13-1308: Promoting Adolescent Health through School-Based HIV/STD Prevention and School-Based Surveillance.

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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:
	80 FR 3238	01/22/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 22192	04/21/2015
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
Web-based CBO Assessment	None	District Partner Assessment - CBO
Web-basedHWC Assessment	None	District Partner Assessment - HWC

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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	60	0	0	60	0	0
Annual Time Burden (Hours)	60	0	0	60	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: 0920-15KX is a New ICR

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Annual Cost to Federal Government: $45,739

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: 04/28/2015

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