Formative Research and Tool Development

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0840 Student Survey	Form	New	Repair queued
Form 0920-0840 Teacher Survey	Form	New	Repair queued
Form 0920-0840 Trauma Informed Approach Survey	Form	New	Repair queued
Form 0920-0840 Micro Session Survey	Form	New	Repair queued
Form 0920-0840 In-person Training Survey	Form	New	Repair queued
Form 0920-0840 Culturally Responsive Health Education Classroom Survey	Form	New	Repair queued
Form 0920-0840 Basic Principles of Teaching Health Education Survey	Form	New	Repair queued
Form 0920-0840 Assess and Adjust Survey	Form	New	Repair queued
Form 0920-0840 Adolescent Growth and Development Survey	Form	New	Repair queued
Form 0920-21CL Consortia Staff Qualitative Discussion Guide and Consent - 90 Min Consortia School Administrators	Form	New	Repair queued
Form 0920-21CL Consortia Staff Qualitative Discussion Guide and Consent - 90 Min Consortia District Level Interview	Form and Instruction	New	Repair queued
Form 0920-20CL Implementation of Health Programming in Schools Web Survey	Form and Instruction	New	Repair queued
Assessment survey - screenshots	Form	New	Repair queued
Assessment survey -word	Form	New	Repair queued
Form 0920-0840 Interview Public Health Professional Guide	Form and Instruction	New	Available
Form 0920-0840 Interview Healthcare Provider Guide B	Form and Instruction	New	Available
Form 0920-0840 Interview Healthcare Provider Guide A	Form and Instruction	New	Available
Form 0920-0840 Interview Adult Guide	Form and Instruction	New	Available
Form 0920-0840 Screener Public Health Professional	Form and Instruction	New	Available
Form 0920-0840 Screener Healthcare Provider	Form and Instruction	New	Available
Form 0920-0840 Screener Adult	Form and Instruction	New	Available
Form 0920-0840 DISCUSSION GUIDE: Virtual Focus Groups with Primary Care Physicians and OBGYNs: Attitudes about Proposed Hepatitis C Screening Guidelines DVH 2019	Form	New	Available
Form 0920-0840 Recruitment Screener	Form and Instruction	New	Available
Form 0920-0840 Formative Evaluation of Professional Development Resources - Web Survey	Form and Instruction	New	Available
Form 0920-0840 Interview Guide	Form and Instruction	New	Available
Form 0920-0840 Interview Scheduling Script	Form and Instruction	New	Available
Form 0920-0840 Recruitment Script	Form and Instruction	New	Available
Professional Outreach Email and Screener	Form and Instruction	New	Available
Recruitment Screener	Form and Instruction	New	Available
Recruitment Screener	Form and Instruction	New	Available
Att 10 List of Approved ICRs.docx	Supplementary Document	Uploaded 2018-08-30	Available
Att 9 Example Consent Form.docx	Supplementary Document	Uploaded 2018-08-30	Available
Att 8 DHAP ConfidAssurance.doc	Supplementary Document	Uploaded 2018-08-30	Available
Att 7 Example Group Interview Guide.doc	Supplementary Document	Uploaded 2018-08-30	Available
Att 6 Sample Screening Tool.doc	Supplementary Document	Uploaded 2018-08-30	Available
Att 5 Example Survey.doc	Supplementary Document	Uploaded 2018-08-30	Available
Att 4 Example Individual Interview Guide.doc	Supplementary Document	Uploaded 2018-08-30	Available
Att 3 Example Questions.doc	Supplementary Document	Uploaded 2018-08-30	Available
Att 2 60 Day FRN.pdf	Supplementary Document	Uploaded 2018-08-30	Available
Att 1 AuthLegislation.doc	Supplementary Document	Uploaded 2018-08-30	Available
SSB.docx	Supporting Statement B	Uploaded 2018-08-30	Available
SSA.docx	Supporting Statement A	Uploaded 2018-08-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Student Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Teacher Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Trauma Informed Approach Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Micro Session Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	In-person Training Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Culturally Responsive Health Education Classroom Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Basic Principles of Teaching Health Education Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Assess and Adjust Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form	New	Adolescent Growth and Development Survey
245526	DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Other-Screenshots	New
245393	DASH DEMO: Understanding Consortia Model Structures for Implementation of Health Programming in Schools	Form	New	Consortia Staff Qualitative Discussion Guide and Consent - 90 Min Consortia School Administrators
245393	DASH DEMO: Understanding Consortia Model Structures for Implementation of Health Programming in Schools	Form and Instruction	New	Consortia Staff Qualitative Discussion Guide and Consent - 90 Min Consortia District Level Interview
245393	DASH DEMO: Understanding Consortia Model Structures for Implementation of Health Programming in Schools	Form and Instruction	New	Implementation of Health Programming in Schools Web Survey
245390	Usability Pilot Test of the ARCH Digital Application for HIV Prevention Providers	Form	New	Assessment survey - screenshots
245390	Usability Pilot Test of the ARCH Digital Application for HIV Prevention Providers	Form	New	Assessment survey -word
240757	Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	Form and Instruction	New	Interview Public Health Professional Guide
240757	Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	Form and Instruction	New	Interview Healthcare Provider Guide B
240757	Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	Form and Instruction	New	Interview Healthcare Provider Guide A
240757	Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	Form and Instruction	New	Interview Adult Guide
240757	Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	Form and Instruction	New	Screener Public Health Professional
240757	Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	Form and Instruction	New	Screener Healthcare Provider
240757	Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	Form and Instruction	New	Screener Adult
238539	Virtual Focus Groups with Primary Care Physicians and OBGYNs	Form	New	DISCUSSION GUIDE: Virtual Focus Groups with Primary Care Physicians and OBGYNs: Attitudes about Proposed Hepatitis C Screening Guidelines DVH 2019
238539	Virtual Focus Groups with Primary Care Physicians and OBGYNs	Form and Instruction	New	Recruitment Screener
238539	Virtual Focus Groups with Primary Care Physicians and OBGYNs	Other-WORD	New
237285	Assessment of Gonorrhea Case Interviewing in SSuN Sites	Other-Interview Guide	New
235815	Formative Evaluation of Professional Development Resources - Web Survey	Form and Instruction	New	Formative Evaluation of Professional Development Resources - Web Survey
235815	Formative Evaluation of Professional Development Resources - Web Survey	Other-WORD	New
235472	Pathways: Qualitative Interviews with Post-Partum Women Associated with Congenital Syphilis Cases (Case Mothers)	Form and Instruction	New	Interview Guide
235472	Pathways: Qualitative Interviews with Post-Partum Women Associated with Congenital Syphilis Cases (Case Mothers)	Form and Instruction	New	Interview Scheduling Script
235472	Pathways: Qualitative Interviews with Post-Partum Women Associated with Congenital Syphilis Cases (Case Mothers)	Form and Instruction	New	Recruitment Script
235234	Health Communication Message Testing on Adolescent Health	Form and Instruction	New	Professional Outreach Email and Screener
235234	Health Communication Message Testing on Adolescent Health	Form and Instruction	New	Recruitment Screener
235234	Health Communication Message Testing on Adolescent Health	Other-Moderator Guide	New
235026	Health Communication Message Testing on Tuberculosis	Form and Instruction	New	Recruitment Screener
235026	Health Communication Message Testing on Tuberculosis	Other-Moderator's Guide	New

ICR Details

OMB Control No: 0920-0840	ICR Reference No: 201808-0920-023
Status: Historical Active	Previous ICR Reference No: 201511-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0840
Title: Formative Research and Tool Development
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/19/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/18/2018
Terms of Clearance: Previous terms continue: OMB approves this umbrella generic, and has informed CDC that each individual study should be submitted into ROCIS an a genIC that includes the actual study instruments and a memo describing the specific study goal, the study design, any incentives to be used, and the sampling and analysis plans.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved	01/31/2019
Responses	121,800	0	121,800
Time Burden (Hours)	46,516	0	46,516
Cost Burden (Dollars)	2,348,936	0	0

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Abstract: The data collection and evidence are developed using a multitude of information sources and short term qualitative interviewing and cognitive research techniques have been proven invaluable in the development of scientifically valid and population-appropriate methods, interventions, and instruments. The activities conducted under this information collection will be used to inform many aspects of surveillance, communications, health promotion, and research project development for the 4 priority diseases (HIV, STDs, TB, and viral hepatitis) as well as school and adolescent health.

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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:
	83 FR 17663	04/23/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 47173	09/18/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Assessment of Gonorrhea Case Interviewing in SSuN Sites
DASH DEMO: Understanding Consortia Model Structures for Implementation of Health Programming in Schools	0920-21CL, 0920-20CL, 0920-21CL	Implementation of Health Programming in Schools Web Survey ,   Consortia Staff Qualitative Discussion Guide and Consent - 90 Min Consortia District Level Interview ,   Consortia Staff Qualitative Discussion Guide and Consent - 90 Min Consortia School Administrators
DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840	Adolescent Growth and Development Survey ,   Assess and Adjust Survey ,   Basic Principles of Teaching Health Education Survey ,   Culturally Responsive Health Education Classroom Survey ,   In-person Training Survey ,   Micro Session Survey ,   Trauma Informed Approach Survey ,   Teacher Survey ,   Student Survey
Formative Evaluation of Professional Development Resources - Web Survey	0920-0840	Formative Evaluation of Professional Development Resources - Web Survey
Health Communication Message Testing on Adolescent Health	none, none	Recruitment Screener ,   Professional Outreach Email and Screener
Health Communication Message Testing on Tuberculosis	none	Recruitment Screener
Pathways: Qualitative Interviews with Post-Partum Women Associated with Congenital Syphilis Cases (Case Mothers)	0920-0840, 0920-0840, 0920-0840	Recruitment Script ,   Interview Scheduling Script ,   Interview Guide
Usability Pilot Test of the ARCH Digital Application for HIV Prevention Providers	none, none	Assessment survey -word ,   Assessment survey - screenshots
Usability Testing to Inform Development of the CDC Division of Sexually Transmitted Disease Prevention's Website	0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840, 0920-0840	Screener Adult ,   Screener Healthcare Provider ,   Screener Public Health Professional ,   Interview Adult Guide ,   Interview Healthcare Provider Guide A ,   Interview Healthcare Provider Guide B ,   Interview Public Health Professional Guide
Virtual Focus Groups with Primary Care Physicians and OBGYNs	0920-0840, 0920-0840	Recruitment Screener ,   DISCUSSION GUIDE: Virtual Focus Groups with Primary Care Physicians and OBGYNs: Attitudes about Proposed Hepatitis C Screening Guidelines DVH 2019

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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	121,800	121,800	0	0	0	0
Annual Time Burden (Hours)	46,516	46,516	0	0	0	0
Annual Cost Burden (Dollars)	2,348,936	0	0	2,348,936	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $574,500

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 09/18/2018

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