Information Collection

DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study

IC 245526 under ICR 201808-0920-023 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0840 Adolescent Growth and Development Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 Assess and Adjust Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 Basic Principles of Teaching Health Education Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 Culturally Responsive Health Education Classroom Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 In-person Training Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 Micro Session Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 Trauma Informed Approach Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 Teacher Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Form 0920-0840 Student Survey DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study	Form
Att 2a_Adolescent Growth and Development_screenshot.pdf	Other-Screenshots
Att 3a_Assess and Adjust_screenshot.pdf	Other-Screenshots
Att 4a_ Basic Principles of Teaching Health Education_screenshots.pdf	Other-Screenshots
Att 5a_Culturally Responsive Health Education Classroom_screenshot.pdf	Other-Screenshots
Att 6a_In-Person Training Evaluation_screenshot.pdf	Other-Screenshots
Att 7a_CHECKS_Micro Session Survey_screenshot.pdf	Other-Screenshots
Att 8a_E-Learning Trauma Informed Approach_screenshot.pdf	Other-Screenshots
Att 9a_Teacher tool_screenshots.pdf	Other-Screenshots
Att 10a_Student Tool_screenthots.pdf	Other-Screenshots
0920-0840 Adolescent Growth and Development Survey Att 2_Adolescent Growth and Development survey.pdf	Form
0920-0840 Assess and Adjust Survey Att 3_Assess and Adjust survey.pdf	Form
0920-0840 Basic Principles of Teaching Health Education Survey Att 4_Basic Principles of Teaching HE_elearning survey.pdf	Form
0920-0840 Culturally Responsive Health Education Classroom Survey Att 5_Culturally Responsive survey.pdf	Form
0920-0840 In-person Training Survey Att 6_In-person training survey.pdf	Form
0920-0840 Micro Session Survey Att 7_Micro session survey.pdf	Form
0920-0840 Trauma Informed Approach Survey Att 8_TIA elearning module survey.pdf	Form
0920-0840 Teacher Survey Att 9_Teacher Survey.pdf	Form
0920-0840 Student Survey Att 10_Student Survey.pdf	Form
Att 11_ CHECKS_Pilot_Invitation Email.pdf Invitation Email	IC Document
Att 11a_CHECKS PD_PIlot_Reminder Email.pdf Reminder Email	IC Document
Att 12 CHECKS PD Pilot_Teacher Consent.pdf Teacher Consent	IC Document
Att 13_ CHECKS PD Pilot_Student Assent Form.pdf Student Assent	IC Document
Att 14_CHECKS PD Pilot_Parental Consent Form.pdf Parental Consent	IC Document
Att 15_IRB Approval.pdf IRB Approval	IC Document
Att 16_Respondent Universe.docx Respondent Universe	IC Document
Att 17_CHECKS PD Pilot_Consultants.docx Consultants	IC Document
Att 18_PIA_CHECKS_PD_Pilot.pdf PIA	IC Document
SSA-CHECKS-3_9_21_Clean.pdf SSA	IC Document
SSB-CHECKS_1_11_20.docx SSB	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study

Agency IC Tracking Number:

0920-0840-20CQ

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only
Form	0920-0840	Yes	Yes	Fillable Fileable
Other-Screenshots		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	662	662
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Invitation Email		02/23/2021
Reminder Email		02/23/2021
Teacher Consent		02/23/2021
Student Assent		02/23/2021
Parental Consent		02/23/2021
IRB Approval		02/23/2021
Respondent Universe		02/23/2021
Consultants		02/23/2021
PIA		02/23/2021
SSA		03/10/2021
SSB		02/25/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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