Media Smart Youth Leaders Program Application Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Media-Smart Youth Leaders Program Application form	Form and Instruction	New	Repair queued
Form 1 Media-Smart Youth Leaders Program Application form	Form and Instruction	New	Repair queued
Form 1 Media-Smart Youth Leaders Program Application form	Form and Instruction	New	Repair queued
0925-New Media Smart Youth (MSY) 30day FRN.pdf	Supplementary Document	Uploaded 2016-02-01	Repair queued
SSA_MSY_NICHD_010416.doc	Supporting Statement A	Uploaded 2016-02-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219922	Media-Smart Youth Leaders Program Application form	Form and Instruction	New
219921	Media-Smart Youth Leaders Program Application form	Form and Instruction	New
219920	Media-Smart Youth Leaders Program Application form	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 201602-0925-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: Media Smart Youth Leaders Program Application Form
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 06/20/2016
	Date Received in OIRA: 02/02/2016
Terms of Clearance: Program requests that ICR be withdrawn as NIH is looking for another group to administer the project.

table that charts list comparision

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

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Abstract: Media-Smart Youth: Eat, Think, and Be Active!® is an interactive program designed to teach youth ages 11–13 about how media can affect their health. Developed by the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the program includes 10 lessons on media analysis, nutrition, and physical activity, plus a final capstone project. The Media-Smart Youth Leaders Program is designed for teens and adults, ages 15 years and up, who are interested in bringing the Media-Smart Youth program to their community. In return for recruiting youth participants, teaching the 10 lessons, and leading the final project, Media-Smart Youth Leaders will receive leadership experience, community service hours, and recognition from the NICHD. To help Leaders succeed, the NICHD will provide training, ongoing assistance, and a small funding award for program expenses. The purpose of this information collection is to solicit information from applicants about their qualifications that would make them effective Leaders, their reason for wanting to pursue this opportunity, and the details of their proposed program (including, but not limited to, location, community partner(s), and proposed budget). This information will help NICHD staff select the candidates for the program who are most likely to succeed in implementing the full curriculum and teaching youth effective lessons about nutrition, physical activity, and media.

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Authorizing Statute(s): PL: Pub.L. 87 - 838 441 Name of Law: An Act to amend the Public Health Service Act to provide for the establishment of an Institute of Ch
  

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 62541	10/16/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 4037	01/25/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Media-Smart Youth Leaders Program Application form	1	Attachment 1 Data Collection Instrument MSY
Media-Smart Youth Leaders Program Application form	1	Attachment 1 Data Collection Instrument MSY
Media-Smart Youth Leaders Program Application form	1	Attachment 1 Data Collection Instrument MSY

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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: new collection

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Annual Cost to Federal Government: $6,552

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 02/02/2016

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