Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
TCU Organizational Readiness Survey	Form	New	Available
Organizational Readiness Survey	Form	New	Available
Clinical Process Improvement Survey	Form	New	Available
NOFAS Post-test Survey	Form	New	Available
NOFAS Pre-test Survey	Form	New	Available
NOFAS Webinar 3 month Survey	Form	New	Available
NOFAS Webinar Survey	Form	New	Available
Social Work and Family Physician Follow-up Survey	Form	New	Available
Social Work and Family Physician Post-training Survey	Form	New	Available
Social Work and Family Physician Pre-training Survey	Form	New	Available
Family Medicine Evaluation	Form	New	Available
FASD Training Evaluation	Form	New	Available
FASD Work Plan	Form	New	Available
FASD Toolkit User Survey	Form	New	Available
AAP Pre-training Survey	Form	New	Available
AAP Pre-training Survey	Form	New	Available
AAP 6 Month Follow-up Survey	Form	New	Available
AAP 3 Month Follow-up Survey	Form	New	Available
Survey of Pediatricians	Form	New	Available
Medical Assistants Change in Practice Survey	Form	New	Available
Medical Assistants Folow-up Survey - Academic	Form	New	Available
Medical Assistants Follow-up Survey	Form	New	Available
Medical Assistants Post-test Survey - Academic	Form	New	Available
Medical Assistants Post-test Survey	Form	New	Available
Medical Assistants Pre-test Survey - Academic	Form	New	Available
Medical Assistants Pre-test Survey	Form	New	Available
OBGYN Telecom Training Survey	Form	New	Available
OBGYN Informant Interview - Posttraining	Form	New	Available
OBGYN Informant Interview - Pretraining	Form	New	Available
OBGYN Training Event Evaluation	Form	New	Available
OBGYN Avatar Training Survey	Form	New	Available
OBGYN Provider Follow-up	Form	New	Available
OBGYN Standardized Patient	Form	New	Repair queued
OBGYN Provider Skills Baseline	Form	New	Available
OBGYN Knowledge and Agency	Form	New	Available
Healthcare Organization Survey	Form	New	Available
Nursing Network Survey	Form	New	Available
Form nopne Nursing Organization Questionnaire	Form	New	Available
Nursing DSW Polling	Form	New	Available
Nursing Training Follow-up Survey	Form	New	Available
Nursing Post-training Survey	Form	New	Available
Nursing Pre-Training Survey	Form	New	Available
DSW Report	Form	New	Available
FASD Training Survey - follow-up	Form	New	Available
FASD Post-training survey	Form	New	Available
FASD Pre-training survey	Form	New	Available
M FASD Evaluation Working Group Members.docx	Supplementary Document	Uploaded 2016-03-02	Available
C Public Comments from 60 Day FRN.pdf	Supplementary Document	Uploaded 2016-03-02	Available
60 Day FRN_CDC-2015-0081-0001.pdf	Supplementary Document	Uploaded 2016-03-02	Available
B Average_ Annualized_Cost_to_the_Federal_Government_12222015.docx	Supplementary Document	Uploaded 2016-03-02	Available
A1 Section 301 of the Public Health Service Act.docx	Supplementary Document	Uploaded 2016-03-02	Available
SupportingStatementPartB_FASD_PICS_and_Partners_Revised02112016.docx	Supporting Statement B	Uploaded 2016-03-02	Available
SupportingStatementPartA_FASD_PICS_and_Partners_Revised02112016.docx	Supporting Statement A	Uploaded 2016-03-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
220433	TCU Organizational Readiness Survey	Form	New	TCU Organizational Readiness Survey
220432	Organizational Readiness Survey	Form	New	Organizational Readiness Survey
220431	Clinical Process Improvement Survey	Form	New	Clinical Process Improvement Survey
220430	NOFAS Post-test Survey	Form	New	NOFAS Post-test Survey
220429	NOFAS Pre-test Survey	Form	New	NOFAS Pre-test Survey
220428	NOFAS Webinar 3 month Survey	Form	New	NOFAS Webinar 3 month Survey
220427	NOFAS Webinar Survey	Form	New	NOFAS Webinar Survey
220426	Social Work and Family Physician Follow-up Survey	Form	New	Social Work and Family Physician Follow-up Survey
220425	Social Work and Family Physician Post-training Survey	Form	New	Social Work and Family Physician Post-training Survey
220423	Social Work and Family Physician Pre-training Survey	Form	New	Social Work and Family Physician Pre-training Survey
220422	Family Medicine Evaluation	Form	New	Family Medicine Evaluation
220421	FASD Training Evaluation	Form	New	FASD Training Evaluation
220419	FASD Work Plan	Form	New	FASD Work Plan
220418	FASD Toolkit Focus Group Guide	Other-Discussion Guide	New
220417	FASD Toolkit User Survey	Form	New	FASD Toolkit User Survey
220416	AAP Post-training Survey	Form	New	AAP Pre-training Survey
220414	AAP Pre-training Survey	Form	New	AAP Pre-training Survey
220412	AAP 6 Month Follow-up Survey	Form	New	AAP 6 Month Follow-up Survey
220411	AAP 3 Month Follow-up Survey	Form	New	AAP 3 Month Follow-up Survey
220410	Pediatricians Survey	Form	New	Survey of Pediatricians
220408	Medical Assistants Change in Practice Survey	Form	New	Medical Assistants Change in Practice Survey
220407	Medical Assistants Follow-up Survey - Academic	Form	New	Medical Assistants Folow-up Survey - Academic
220405	Medical Assistants Follow-up Survey	Form	New	Medical Assistants Follow-up Survey
220404	Medical Assistants Post-test Survey - Academic	Form	New	Medical Assistants Post-test Survey - Academic
220403	Medical Assistants Post-test Survey	Form	New	Medical Assistants Post-test Survey
220402	Medical Assistants Pre-test Survey - Academic	Form	New	Medical Assistants Pre-test Survey - Academic
220401	Medical Assistants Pre-test Survey	Form	New	Medical Assistants Pre-test Survey
220400	OBGYN Telecom Training Survey	Form	New	OBGYN Telecom Training Survey
220399	OBGYN Informant Interview - Posttraining	Form	New	OBGYN Informant Interview - Posttraining
220398	OBGYN Informant Interview - Pretraining	Form	New	OBGYN Informant Interview - Pretraining
220397	OBGYN Training Event Evaluation	Form	New	OBGYN Training Event Evaluation
220396	OBGYN Avatar Training Survey	Form	New	OBGYN Avatar Training Survey
220395	OBGYN Provider Follow-up	Form	New	OBGYN Provider Follow-up
220394	OBGYN Standardized Patient	Form	New	OBGYN Standardized Patient
220392	OBGYN Provider Skills Baseline	Form	New	OBGYN Provider Skills Baseline
220391	OBGYN Knowledge and Agency	Form	New	OBGYN Knowledge and Agency
220390	Healthcare Organization Survey	Form	New	Healthcare Organization Survey
220389	Nursing Network Survey	Form	New	Nursing Network Survey
220388	Nursing Organization Questionnaire	Form	New	Nursing Organization Questionnaire
220387	Nursing Informant Interview	Other-Interview Guide	New
220386	Nursing DSW Polling	Form	New	Nursing DSW Polling
220385	Nursing Follow-up Training Survey	Form	New	Nursing Training Follow-up Survey
220384	Nursing Post-training Survey	Form	New	Nursing Post-training Survey
220383	Nursing Pre-training Survey	Form	New	Nursing Pre-Training Survey
220382	High Impact Study - Informant Interview	Other-Interview Guide	New
220381	HIgh Impact Study - Discussion Guide	Other-Discussion Guide	New
220379	DSW Report	Form	New	DSW Report
220378	FASD Core Training - 6 month follow-up	Form	New	FASD Training Survey - follow-up
220377	FASD Core Training Survey - Post-test	Form	New	FASD Post-training survey
220375	FASD Core Training Survey Pretest	Form	New	FASD Pre-training survey

ICR Details

OMB Control No: 0920-1129	ICR Reference No: 201603-0920-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15BEZ
Title: Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships
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 without change	Conclusion Date: 08/04/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/09/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved
Responses	31,577	0	0
Time Burden (Hours)	3,776	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goals of this project are to evaluate the collaboration between the Practice and Implementation Centers (PICs) and national partners organizations, and to evaluate the work of the PICs and partners.

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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 55362	09/15/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 11801	03/07/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 50

table that charts list of burden

IC Title	Form No.	Form Name
AAP 3 Month Follow-up Survey	none	AAP 3 Month Follow-up Survey
AAP 6 Month Follow-up Survey	none	AAP 6 Month Follow-up Survey
AAP Post-training Survey	none	AAP Pre-training Survey
AAP Pre-training Survey	none	AAP Pre-training Survey
Clinical Process Improvement Survey	none	Clinical Process Improvement Survey
DSW Report	none	DSW Report
FASD Core Training - 6 month follow-up	none	FASD Training Survey - follow-up
FASD Core Training Survey - Post-test	none	FASD Post-training survey
FASD Core Training Survey Pretest	none	FASD Pre-training survey
FASD Toolkit Focus Group Guide
FASD Toolkit User Survey	none	FASD Toolkit User Survey
FASD Training Evaluation	none	FASD Training Evaluation
FASD Work Plan	none	FASD Work Plan
Family Medicine Evaluation	none	Family Medicine Evaluation
HIgh Impact Study - Discussion Guide
Healthcare Organization Survey	none	Healthcare Organization Survey
High Impact Study - Informant Interview
Medical Assistants Change in Practice Survey	none	Medical Assistants Change in Practice Survey
Medical Assistants Follow-up Survey	none	Medical Assistants Follow-up Survey
Medical Assistants Follow-up Survey - Academic	none	Medical Assistants Folow-up Survey - Academic
Medical Assistants Post-test Survey	none	Medical Assistants Post-test Survey
Medical Assistants Post-test Survey - Academic	none	Medical Assistants Post-test Survey - Academic
Medical Assistants Pre-test Survey	none	Medical Assistants Pre-test Survey
Medical Assistants Pre-test Survey - Academic	none	Medical Assistants Pre-test Survey - Academic
NOFAS Post-test Survey	none	NOFAS Post-test Survey
NOFAS Pre-test Survey	none	NOFAS Pre-test Survey
NOFAS Webinar 3 month Survey	none	NOFAS Webinar 3 month Survey
NOFAS Webinar Survey	none	NOFAS Webinar Survey
Nursing DSW Polling	none	Nursing DSW Polling
Nursing Follow-up Training Survey	none	Nursing Training Follow-up Survey
Nursing Informant Interview
Nursing Network Survey	none	Nursing Network Survey
Nursing Organization Questionnaire	nopne	Nursing Organization Questionnaire
Nursing Post-training Survey	none	Nursing Post-training Survey
Nursing Pre-training Survey	none	Nursing Pre-Training Survey
OBGYN Avatar Training Survey	none	OBGYN Avatar Training Survey
OBGYN Informant Interview - Posttraining	none	OBGYN Informant Interview - Posttraining
OBGYN Informant Interview - Pretraining	none	OBGYN Informant Interview - Pretraining
OBGYN Knowledge and Agency	none	OBGYN Knowledge and Agency
OBGYN Provider Follow-up	none	OBGYN Provider Follow-up
OBGYN Provider Skills Baseline	none	OBGYN Provider Skills Baseline
OBGYN Standardized Patient	none	OBGYN Standardized Patient
OBGYN Telecom Training Survey	none	OBGYN Telecom Training Survey
OBGYN Training Event Evaluation	none	OBGYN Training Event Evaluation
Organizational Readiness Survey	none	Organizational Readiness Survey
Pediatricians Survey	none	Survey of Pediatricians
Social Work and Family Physician Follow-up Survey	none	Social Work and Family Physician Follow-up Survey
Social Work and Family Physician Post-training Survey	none	Social Work and Family Physician Post-training Survey
Social Work and Family Physician Pre-training Survey	none	Social Work and Family Physician Pre-training Survey
TCU Organizational Readiness Survey	none	TCU Organizational Readiness Survey

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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	31,577	0	0	31,577	0	0
Annual Time Burden (Hours)	3,776	0	0	3,776	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: $1,603,724

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: 03/09/2016

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