Promoting Adolescent Health through School-Based HIV Prevention

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-19AUK District Assistance Questionnaire	Form and Instruction	New	Available
Form 0920-19AUK Priority School Questionnaire	Form and Instruction	New	Available
Form 0920-19AUK Funded District Questionnaire	Form and Instruction	New	Available
Att13 PIA_Form.docx	Supplementary Document	Uploaded 2019-11-22	Available
SSA.docx	Supporting Statement A	Uploaded 2019-08-30	Available
Att13 PIA_Form- signed.pdf	Supplementary Document	Uploaded 2019-11-22	Available
Att12-SCDC ASTDR IRB Determination.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att11-CDC Program Eval Framework.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att10-Analysis of Alternatives.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att9c-SSE Rationale.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att9b-SHS Rationale.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att9a-SHE Rationale.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att7-LEAs Providing Feedback.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att6-List of Funded LEAs.docx	Supplementary Document	Uploaded 2019-08-30	Available
Att2-60 Day FRN Published.pdf	Supplementary Document	Uploaded 2019-08-30	Available
Att1-Authorizing Legislation.docx	Supplementary Document	Uploaded 2019-08-30	Available
SSB.docx	Supporting Statement B	Uploaded 2019-08-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237606	District Assistance Questionnaire	Form and Instruction	New
237604	Priority School Questionnaire	Form and Instruction	New
237602	Funded District Questionnaire	Form and Instruction	New

ICR Details

OMB Control No: 0920-1275	ICR Reference No: 201908-0920-010
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-19AUK
Title: Promoting Adolescent Health through School-Based HIV Prevention
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 with change	Conclusion Date: 11/25/2019
	Date Received in OIRA: 09/11/2019
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved
Responses	150	0	0
Time Burden (Hours)	1,750	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this request is to obtain a three-year approval for data collection using a Web-based program evaluation and monitoring system, the Program Evaluation and Reporting System (PERS), that will use questionnaires to allow the Division of Adolescent and School Health, (DASH) at the Centers for Disease Control and Prevention (CDC) to organize, plan, and track activities conducted by funded Local Education Agencies (LEAs) under NOFO PS18-1807 Promoting Adolescent Health through School-Based HIV/STD Prevention and School-Based Surveillance.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

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:
	84 FR 26113	06/05/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 47956	09/11/2019
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
District Assistance Questionnaire	0920-19AUK	District Assistance Questionnaire
Priority School Questionnaire	0920-19AUK	Priority School Questionnaire
Funded District Questionnaire	0920-19AUK	Funded District Questionnaire

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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	150	0	0	150	0	0
Annual Time Burden (Hours)	1,750	0	0	1,750	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 Collection.

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Annual Cost to Federal Government: $498,851

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 09/11/2019

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