Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

Forms and Documents

Document Name	Status
Form 0920-1129 TCU Organizational Readiness Survey Form and Instruction	New
Form 0920-1129 Social Work and Family Physicians 6 Month Follow-Up Form and Instruction	New
Form 0292-1129 Post-Test Treatment Across the Lifespan Form and Instruction	New
Form 0920-1129 Post-Test ND-PAE Form and Instruction	New
Form 0920-1129 Pre-Test ND-PAE Form and Instruction	New
Form 0920-1129 Post-Test Screening, Assessment, and Diagnosis Form and Instruction	New
Form 0920-1129 Medical Assistants Change in Practice Survey Form and Instruction	New
Form 0920-1129 Medical Assistants Post-Test Survey Form and Instruction	New
Form 0920-1129 Key Informant Interviews with Champions Form and Instruction	New
Form 092-1129 Health Professionals Survey (Nursing) Form and Instruction	New
Form 0920-1129 FASD Core Training Survey Post-Test Form and Instruction	New
Form 0920-1129 Core Pre Test Form and Instruction	New
Form 0920-1129 Health Professionals Survey Form and Instruction	New
TCU Organizational Readiness Survey Form	Removed
Organizational Readiness Survey Form	Removed
Clinical Process Improvement Survey Form	Removed
Form 0920-1129 FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation (previously NO FAS Post-Test Survey) Form and Instruction	Removed
Form 0920-1129 FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation (previously NOFAS Pre-Test Survey) Form and Instruction	Removed
NOFAS Webinar 3 month Survey Form	Removed
NOFAS Webinar Survey Form	Removed
Social Work and Family Physician Follow-up Survey Form	Removed
Social Work and Family Physician Post-training Survey Form	Removed
Social Work and Family Physician Pre-training Survey Form	Removed
Family Medicine Evaluation Form	Removed
FASD Training Evaluation Form	Removed
FASD Work Plan Form	Removed
FASD Toolkit User Survey Form	Removed
Form 0920-1129 AAP Post-Training Evaluation Survey (Pediatrics) Form and Instruction	Removed
Form 0920-1129 AAP Pre-Training Evaluation Survey (Pediatrics) Form and Instruction	Removed
Form 0920-1129 AAP 6 Month Follow-up Evaluation Survey (Pediatrics) Form and Instruction	Removed
Form 0920-1129 AAP 3 Month Follow-up Survey (Pediatrics) Form and Instruction	Removed
Pediatricians Survey Form	Removed
Medical Assistants Change in Practice Survey Form	Removed
Medical Assistants Follow-up Survey - Academic Form	Removed
Medical Assistants Follow-up Survey Form	Removed
Medical Assistants Post-test Survey - Academic Form	Removed
Medical Assistants Post-test Survey Form	Removed
Medical Assistants Pre-test Survey - Academic Form	Removed
Medical Assistants Pre-test Survey Form	Removed
OBGYN Informant Interview - Posttraining Form	Removed
OBGYN Informant Interview - Pretraining Form	Removed
Form 0920-1129 OBGYN FASD-SBI Training Event Evaluation Form and Instruction	Removed
Form 0920-1129 OBGYN Guided Brief Intervention Satisfactory Survey (previously OBGYN Avatar Training Satisfaction Survey) Form and Instruction	Removed
OBGYN Provider Follow-up Form	Removed
OBGYN Standardized Patient Form	Removed
OBGYN Provider Skills Baseline Form	Removed
OBGYN Knowledge and Agency Form	Removed
Healthcare Organization Survey Form	Removed
Nursing Network Survey Form	Removed
Form nopne Nursing Organization Questionnaire Form	Removed
Nursing DSW Polling Form	Removed
Six-Month Follow-Up Training Survey (Nursing) Form	Removed
Pre-Training Survey (Nursing) Form	Removed
Pre-Training Survey (Nursing) Form	Removed
DSW Report Form	Removed
FASD Core Training - 6 month follow-up Form	Removed
FASD Core Training Survey - Post-test Form	Removed
Form 0920-1129 FASD Core Training Survey Pre-test Form and Instruction	Removed
D3 Social Work & Family Physicians 6 Month Follow Up Survey_Web-based version.pdf Supplementary Document	2021-02-05
D2 Social Work & Family Physicians Pre-Training Survey_Web-based version.pdf Supplementary Document	2021-02-05
D1 Medical Assistants Change in Practice Survey_Web-based version.pdf Supplementary Document	2021-02-05
7. Att.A_Authorizing Language_A1 Section 301 of the Public Health Service Act_0920-1129.docx Supplementary Document	2021-02-03
5. IRB Form_0920-1129 Improving FASD.pdf Supplementary Document	2021-02-03
60Day FRN 101320.pdf Supplementary Document	2021-02-03
30 Day FRN 012820.pdf Supplementary Document	2021-02-03
2. SupportingStatementPartB_0920-1129 Improving FASD 12 08 2020_30DayFRN.docx Supporting Statement B	2021-02-03
1. SupportingStatementPartA_0920-1129 Improving FASD 12 8 2020.docx Supporting Statement A	2021-02-03

IC Document Collections

IC ID	Document Title	Status
245669	TCU Organizational Readiness Survey Form and Instruction	New
245668	Social Work and Family Physicians 6 Month Follow-Up Form and Instruction	New
245667	Social Work and Family Physicians Pre-Training Survey	New
245666	Post-Test Treatment Across the Lifespan Form and Instruction	New
245665	Pre-Test Treatment Across the Lifespan	New
245664	Post-Test ND-PAE Form and Instruction	New
245663	Pre-Test ND-PAE Form and Instruction	New
245662	Post-Test Screening, Assessment, and Diagnosis Form and Instruction	New
245661	Pre-Test Screening, Assessment, and Diagnosis	New
245659	Medical Assistants Change in Practice Survey Form and Instruction	New
245656	Medical Assistants Post-Test Survey Form and Instruction	New
245653	Medical Assistants Pre-Test Survey	New
245652	Key Informant Interviews with Champions Form and Instruction	New
245650	Health Professionals Survey (Nursing) Form and Instruction	New
245648	FASD Core Training Survey Post-Test Form and Instruction	New
245559	Core Pre Test Form and Instruction	New
245558	Health Professionals Survey Form and Instruction	New
220433	TCU Organizational Readiness Survey Form	Removed
220432	Organizational Readiness Survey Form	Removed
220431	Clinical Process Improvement Survey Form	Removed
220430	FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation (previously NO FAS Post-Test Survey) Form and Instruction	Removed
220429	FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation (previously NOFAS Pre-Test Survey) Form and Instruction	Removed
220428	NOFAS Webinar 3 month Survey Form	Removed
220427	NOFAS Webinar Survey Form	Removed
220426	Social Work and Family Physician Follow-up Survey Form	Removed
220425	Social Work and Family Physician Post-training Survey Form	Removed
220423	Social Work and Family Physician Pre-training Survey Form	Removed
220422	Family Medicine Evaluation Form	Removed
220421	FASD Training Evaluation Form	Removed
220419	FASD Work Plan Form	Removed
220418	FASD Toolkit Focus Group Guide Other-Discussion Guide	Removed
220417	FASD Toolkit User Survey Form	Removed
220416	AAP Post-Training Evaluation Survey (Pediatrics) Form and Instruction	Removed
220414	AAP Pre-Training Evaluation Survey (Pediatrics) Form and Instruction	Removed
220412	AAP 6 Month Follow-up Evaluation Survey (Pediatrics) Form and Instruction	Removed
220411	AAP 3 Month Follow-up Survey (Pediatrics) Form and Instruction	Removed
220410	Pediatricians Survey Form	Removed
220408	Medical Assistants Change in Practice Survey Form	Removed
220407	Medical Assistants Follow-up Survey - Academic Form	Removed
220405	Medical Assistants Follow-up Survey Form	Removed
220404	Medical Assistants Post-test Survey - Academic Form	Removed
220403	Medical Assistants Post-test Survey Form	Removed
220402	Medical Assistants Pre-test Survey - Academic Form	Removed
220401	Medical Assistants Pre-test Survey Form	Removed
220400	OBGYN Telecom Training Survey Other-WORD	Removed
220399	OBGYN Informant Interview - Posttraining Form	Removed
220398	OBGYN Informant Interview - Pretraining Form	Removed
220397	OBGYN FASD-SBI Training Event Evaluation Form and Instruction	Removed
220396	OBGYN Guided Brief Intervention Satisfactory Survey (previously OBGYN Avatar Training Satisfaction Survey) Form and Instruction	Removed
220395	OBGYN Provider Follow-up Form	Removed
220394	OBGYN Standardized Patient Form	Removed
220392	OBGYN Provider Skills Baseline Form	Removed
220391	OBGYN Knowledge and Agency Form	Removed
220390	Healthcare Organization Survey Form	Removed
220389	Nursing Network Survey Form	Removed
220388	Nursing Organization Questionnaire Form	Removed
220387	Nursing Informant Interview Other-Interview Guide	Removed
220386	Nursing DSW Polling Form	Removed
220385	Six-Month Follow-Up Training Survey (Nursing) Form	Removed
220384	Pre-Training Survey (Nursing) Form	Removed
220383	Pre-Training Survey (Nursing) Form	Removed
220382	High Impact Study - Informant Interview Other-Interview Guide	Removed
220381	HIgh Impact Study - Discussion Guide Other-Discussion Guide	Removed
220379	DSW Report Form	Removed
220378	FASD Core Training - 6 month follow-up Form	Removed
220377	FASD Core Training Survey - Post-test Form	Removed
220375	FASD Core Training Survey Pre-test Form and Instruction	Removed

ICR Details

OMB Control No: 0920-1129	ICR Reference No: 202102-0920-003
Status: Received in OIRA	Previous ICR Reference No: 201707-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1129
Title: Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/08/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	16,938	0
Time Burden (Hours)	2,332	0
Cost Burden (Dollars)	0	0

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Abstract: The purpose of this information collection is to assess and address the knowledge, attitude, skills and practice behaviors of healthcare professionals to prevent, identify, and treat fetal alcohol spectrum disorders (FASDs). Data collected will be used to inform the development of, and determine the effectiveness of, trainings and other resources for the prevention, identification, and treatment of FASDs. Needs assessment and training data will be collected either electronically, via paper/pencil, or web-based survey. Qualitative data collections will be conducted by phone or in-person.

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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:
	85 FR 64469	10/13/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 7396	01/28/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

IC Title	Form No.	Form Name
Medical Assistants Post-Test Survey	0920-1129	B7 Medical Assistants Post-Test Survey
Post-Test Screening, Assessment, and Diagnosis	0920-1129	B10 Post-Test Screening, Assessment and Diagnosis
Pre-Training Survey (Nursing)	none	Nursing Pre-Training Survey
Six-Month Follow-Up Training Survey (Nursing)	none	Nursing Training Follow-up Survey
Organizational Readiness Survey	none	Organizational Readiness Survey
Pre-Training Survey (Nursing)	none	Nursing Post-training Survey
FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation (previously NO FAS Post-Test Survey)	0920-1129	FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation
Clinical Process Improvement Survey	none	Clinical Process Improvement Survey
High Impact Study - Informant Interview
Nursing DSW Polling	none	Nursing DSW Polling
TCU Organizational Readiness Survey	none	TCU Organizational Readiness Survey
FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation (previously NOFAS Pre-Test Survey)	0920-1129	FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation
NOFAS Webinar 3 month Survey	none	NOFAS Webinar 3 month Survey
OBGYN Provider Follow-up	none	OBGYN Provider Follow-up
Social Work and Family Physician Follow-up Survey	none	Social Work and Family Physician Follow-up Survey
OBGYN FASD-SBI Training Event Evaluation	0920-1129	OBGYN FASD-SBI Training Event Evaluation
OBGYN Informant Interview - Pretraining	none	OBGYN Informant Interview - Pretraining
OBGYN Knowledge and Agency	none	OBGYN Knowledge and Agency
Nursing Organization Questionnaire	nopne	Nursing Organization Questionnaire
Nursing Informant Interview
NOFAS Webinar Survey	none	NOFAS Webinar Survey
Medical Assistants Change in Practice Survey	none	Medical Assistants Change in Practice Survey
AAP 6 Month Follow-up Evaluation Survey (Pediatrics)	0920-1129	AAP Six-Month Follow-Up Evaluation Survey
Nursing Network Survey	none	Nursing Network Survey
Healthcare Organization Survey	none	Healthcare Organization Survey
OBGYN Provider Skills Baseline	none	OBGYN Provider Skills Baseline
Social Work and Family Physician Post-training Survey	none	Social Work and Family Physician Post-training Survey
OBGYN Guided Brief Intervention Satisfactory Survey (previously OBGYN Avatar Training Satisfaction Survey)	0920-1129	OBGYN Guided Brief Intervention Satisfaction Survey
Social Work and Family Physician Pre-training Survey	none	Social Work and Family Physician Pre-training Survey
Pediatricians Survey	none	Survey of Pediatricians
AAP 3 Month Follow-up Survey (Pediatrics)	0920-1129	AAP Three-month Follow-up Evaluation Survey
AAP Pre-Training Evaluation Survey (Pediatrics)	0920-1129	Academia Americana De Pediatria Encuesta De Evaluacion De Seguimento De 6 Meses
FASD Core Training - 6 month follow-up	none	FASD Training Survey - follow-up
DSW Report	none	DSW Report
OBGYN Standardized Patient	none	OBGYN Standardized Patient
OBGYN Informant Interview - Posttraining	none	OBGYN Informant Interview - Posttraining
OBGYN Telecom Training Survey	0920-1129	OBGYN Telecom Training Satisfaction Survey (TTS)
Medical Assistants Pre-test Survey	none	Medical Assistants Pre-test Survey
Medical Assistants Pre-test Survey - Academic	none	Medical Assistants Pre-test Survey - Academic
Medical Assistants Follow-up Survey - Academic	none	Medical Assistants Folow-up Survey - Academic
Family Medicine Evaluation	none	Family Medicine Evaluation
AAP Post-Training Evaluation Survey (Pediatrics)	0920-1129	Academia Americana De Pediatria Ciiestionario De Elaluacion Posterior A La Capacitacion
FASD Training Evaluation	none	FASD Training Evaluation
Medical Assistants Post-test Survey - Academic	none	Medical Assistants Post-test Survey - Academic
FASD Toolkit User Survey	none	FASD Toolkit User Survey
Key Informant Interviews with Champions	0920-1129	B5 Key Informant Interviews with Champions
Medical Assistants Pre-Test Survey
HIgh Impact Study - Discussion Guide
FASD Core Training Survey Post-Test	0920-1129	Core Post-Training Survey
Health Professionals Survey (Nursing)	092-1129	Health Professionals Survey_Nursing
Medical Assistants Change in Practice Survey	0920-1129	B8 Medical Assistants Change in Practice Survey
FASD Toolkit Focus Group Guide
FASD Work Plan	none	FASD Work Plan
Health Professionals Survey	0920-1129	Health Professionals Survey
Core Pre Test	0920-1129	Core Pre-Test Survey
FASD Core Training Survey - Post-test	none	FASD Post-training survey
Medical Assistants Post-test Survey	none	Medical Assistants Post-test Survey
Medical Assistants Follow-up Survey	none	Medical Assistants Follow-up Survey
FASD Core Training Survey Pre-test	0920-1129	FASD Prevention, Identification & Alcohol Screening Pre-Training Evaluation
Pre-Test Screening, Assessment, and Diagnosis
Pre-Test ND-PAE	0920-1129	B11 Pre-test ND-PAE
Post-Test ND-PAE	0920-1129	B12 Post-test ND-PAE
Pre-Test Treatment Across the Lifespan
Post-Test Treatment Across the Lifespan	0292-1129	B14 Post-Test Treatment Across Lifespan
Social Work and Family Physicians Pre-Training Survey
Social Work and Family Physicians 6 Month Follow-Up	0920-1129	B16 Social Work & Family Physicians Pre-Training SurveyWeb-based version
TCU Organizational Readiness Survey	0920-1129	B17 TCU Organizational Readiness Survey

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ICR Summary of Burden

	Total Request	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	16,938	0	0	16,938	-31,577	31,577
Annual Time Burden (Hours)	2,332	0	0	2,332	-3,748	3,748
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: CDC is requesting approval for 2,338 burden hours. This reinstatement is requesting a decreased burden time (previously 3709 hrs.). This change largely occurs due to the reduction in the number of instruments being used. The total number of data collection instruments has decreased by 33 instruments. This notice has a 30-day comment period; CDC is requesting a three-year approval.

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Annual Cost to Federal Government: $830,120

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? No

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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: 02/08/2021

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