Information Collection Request

Performance Monitoring of “Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations

ICR 201912-0920-012 · OMB 0920-1156 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Youth Serving Organization (YSO) Staff Survey Form and Instruction Removed Available
Youth Serving Organization (YSO) Performance Measure Reporting Tool Form Removed Available
Youth Serving Organization (YSO) Organizational Assessment Form Removed Available
Form 0920-1156 Health Center Provider Survey Form and Instruction Modified Available
Form 0920-1156 Annual Health Center Performance Measure Reporting Tool Form and Instruction Modified Available
Form 0920-1156 Quarterly Health Center Perfoemance Measure Reporting Tool Form and Instruction Modified Available
Form 0920-1156 Health Center Organizational Assessment Form and Instruction Modified Repair queued
Health Center Youth Survey Form and Instruction Removed Available
Form 0920-1156 Awardee Performance Measure Reporting Tool Form and Instruction Modified Repair queued
Form 0920-1156 Awardee Training and Techmnical Assistance Tool Form and Instruction Modified Available
Youth Serving Organization (YSO) Staff Survey Form and Instruction Removed Available
Youth Serving Organization (YSO) Performance Measure Reporting Tool Form and Instruction Removed Repair queued
Youth Serving Organization (YSO) Organizational Assessment Form and Instruction Removed Available
Form 0920-1156 Health Center Provider Survey Form and Instruction Modified Repair queued
Form 0920-1156 Annual Health Center Performance Measure Reporting Tool Form and Instruction Modified Available
Form 0920-1156 Quarterly Health Center Performance Measure Reporting Tool Form and Instruction Modified Available
Form 0920-1156 Health Center Organizational Assessment Form and Instruction Modified Available
Research Determination Teen Preg Final.pdf Supplementary Document Uploaded 2020-01-24 Available
Att 10a 60 day Federal Register Notice.pdf Supplementary Document Uploaded 2020-01-24 Available
Att 9 logic model.docx Supplementary Document Uploaded 2020-01-24 Available
Att 2 Crosswalk of Objectives and Data Sources_080219.docx Supplementary Document Uploaded 2020-01-24 Available
Att 1-Authorizing Legislation.pdf Supplementary Document Uploaded 2020-01-24 Available
SSB Working with Public Centers Teen Preg ICRO Final.docx Supporting Statement B Uploaded 2020-01-24 Available
SSA Working with Public Centers Teen Preg ICRO Final.docx Supporting Statement A Uploaded 2020-01-24 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
222392 Youth Serving Organization (YSO) Staff Survey Form and Instruction Removed
222389 Youth Serving Organization (YSO) Performance Measure Reporting Tool Form Removed
222387 Youth Serving Organization (YSO) Organizational Assessment Form Removed
222386 Health Center Provider Survey Form and Instruction Modified
222376 Annual Health Center Performance Measure Reporting Tool Form and Instruction Modified
222375 Quarterly Health Center Perfoemance Measure Reporting Tool Form and Instruction Modified
222374 Health Center Organizational Assessment Form and Instruction Modified
222373 Health Center Youth Survey Form and Instruction Removed
222372 Awardee Performance Measure Reporting Tool Form and Instruction Modified
222371 Awardee Training and Techmnical Assistance Tool Form and Instruction Modified
222370 Youth Serving Organization (YSO) Staff Survey Form and Instruction Removed
222369 Youth Serving Organization (YSO) Performance Measure Reporting Tool Form and Instruction Removed
222368 Youth Serving Organization (YSO) Organizational Assessment Form and Instruction Removed
222367 Health Center Provider Survey Form and Instruction Modified
222366 Annual Health Center Performance Measure Reporting Tool Form and Instruction Modified
222365 Quarterly Health Center Performance Measure Reporting Tool Form and Instruction Modified
222364 Health Center Organizational Assessment Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2021 8 Months From Approved 04/30/2020
227 0 2,064
485 0 1,150
0 0 0





Reginfo record details
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table that charts list of burden
IC Title Form No. Form Name
Health Center Provider Survey 0920-1156, 0920-1156 Health Center Provider Survey Online ,   Health Center Provider Survey
Annual Health Center Performance Measure Reporting Tool 0920-1156, 0920-1156 Annual Health Center Performance Measure Reporting Tool ,   Annual Health Center Performance Measure Reporting Tool Online
Awardee Performance Measure Reporting Tool 0920-1156, 0920-1156 Awardee Performance Measure Reporting Tool ,   Awardee Performance Measure Reporting Tool Online
Annual Health Center Performance Measure Reporting Tool 0920-1156, 0920-1156 Annual Health Center Perfornce Meure Repting Tool ,   Annual Health Center Performance Measure Reporting Tool Online
Health Center Organizational Assessment 0920-1156, 0920-1156 Health Center Org Assessment ,   Health Center Org Assessment Online
Quarterly Health Center Performance Measure Reporting Tool 0920-1156, 0920-1156 Quarterly Health Center Performance Measure Reporting Tool ,   Quarterly Health Center Performance Measure Reporting Tool Online
Health Center Provider Survey 0920-1156, 0920-1156 Health Center Provider Survey ,   Health Center Provider Survey Online
Awardee Training and Techmnical Assistance Tool 0920-1156 Awardee Training and Technical Assistance Tool
Quarterly Health Center Perfoemance Measure Reporting Tool 0920-1156, 0920-1156 Quarterly Health Center Performance Measure Reporting Tool Online ,   Quarterly Health Center Performance Measure Reporting Tool
Health Center Organizational Assessment 0920-1156, 0920-1156 Health Center Org Assessment ,   Health Center Org Assessment Online
Youth Serving Organization (YSO) Organizational Assessment N/A, N/A Att 6a Health Center Youth Survey Online Version ,   Att 6a Health Center Youth Survey Online Version
Youth Serving Organization (YSO) Performance Measure Reporting Tool NA Youth Serving Organization Performance Measure Reporting Tool
Youth Serving Organization (YSO) Staff Survey N/A, N/A Att 10 YSO Staff Survey clean ,   Att 10a YSO Staff Survey Online Version
Health Center Youth Survey NA Helath Center Youth Survey
Youth Serving Organization (YSO) Organizational Assessment N/A Att 9a YSO Organizational Assessment Online Version
Youth Serving Organization (YSO) Performance Measure Reporting Tool N/A Att 11a YSO Performance Measure Reporting Tool Online Version
Youth Serving Organization (YSO) Staff Survey NA Youth Serving Organization (YSO) Staff Survey

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 227 2,064 0 -87 -1,750 0
Annual Time Burden (Hours) 485 1,150 0 -140 -525 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
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