DELTA Impact Recipient Monitoring and Assessment Tools

Forms and Documents

Document Name	Status
Form 0920-18FO Annual Progress Report Tool Form and Instruction	New
Att. 7. IRB - Research Determination DELTA Impact.pdf Supplementary Document	2018-09-17
Att. 6. Privacy Act applicability.pdf Supplementary Document	2018-09-17
Att. 5.FRN 60 Dy 0920-18FO DELTA IMPACT.pdf Supplementary Document	2018-09-17
Att. 4 Crosswalk of Evaluation Questions.docx Supplementary Document	2018-09-17
Att. 3a. Screenshots APR Tool.docx Supplementary Document	2018-09-17
Att. 2. List of Grantees.docx Supplementary Document	2018-09-17
Att. 1 Authorizing Legislation FVPSA-DELTA Impact.pdf Supplementary Document	2018-09-17
SSB 19FO _ DELTA Impact 8.14.18.docx Supporting Statement B	2018-09-17
SSA 19FO _ DELTA Impact 9.15.18_ICRO.docx Supporting Statement A	2018-09-17

IC Document Collections

IC ID	Document Title	Status
233035	Annual Progress Report Tool Form and Instruction	New

ICR Details

OMB Control No: 0920-1247	ICR Reference No: 201809-0920-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-18FO
Title: DELTA Impact Recipient Monitoring and Assessment Tools
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: 11/14/2018
	Date Received in OIRA: 10/11/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2021	36 Months From Approved
Responses	10	0	0
Time Burden (Hours)	117	0	0
Cost Burden (Dollars)	3,586	0	0

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Abstract: Collect information from recipients related to implementation and performance monitoring of cooperative agreement CDC-RFA-CE18-1801: Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Impact. Information to be collected will provide crucial data for performance monitoring, implementation of prevention strategies, and budget tracking.

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Authorizing Statute(s): US Code: 42 USC 10414 Name of Law: Family Violence and Prevention Services Act (FVPSA)
  

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 2782	01/19/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 50933	10/10/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Annual Progress Report Tool	0920-18FO	APR Tool

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ICR Summary 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	10	0	0	10	0	0
Annual Time Burden (Hours)	117	0	0	117	0	0
Annual Cost Burden (Dollars)	3,586	0	0	3,586	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: $49,000

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: 10/11/2018

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