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PAPERWORK REDUCTION ACT DETERMINATION FORM
AUTHORITY: The Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520), 5 Code of Federal Regulations (CFR) Part 1320
PRINCIPAL PURPOSES: To determine applicability of Centers for Disease Control and Prevention (CDC) proposed projects for Paperwork Reduction Act
(PRA) compliance. Proper completion of this form will prevent both illegal information collections and PRA violations.
ROUTINE USES: Information is disclosed to the Information Collection Review Office (ICRO) for auditing and quality assurance purposes.
MANDATORY DISCLOSURE: Failure to provide complete information and the necessary supporting documents may delay proposed project activities.
As a Federal Government agency, CDC is subject to the PRA. The information on this form is required to make a project’s PRA applicability
determination. This form (pages 1 and 2) must be completed by the Center, Institute, Office (CIO) PRA Contact. A copy of the related supporting
documents that identify all proposed project collection of information (reporting), retention of information (recordkeeping), and disclosure of
information (disclosing) activities must accompany this form upon submittal to ICRO via [email protected].
I. Center, Institute, Office (CIO) Information
CIO Abbreviation: NCHHSTP
CIO PRA Contact: Name (Last, First)

CDC E-mail:

Phone No.:

Bond, Constance
Project Officer/Investigator/Point of Contact: Name (Last, First)

[email protected]
CDC E-mail:

404-718-8548
Phone No.:

Szucs, Leigh
Project Title: LGBTQ Inclusivity Toolkit Demonstration Project

[email protected]

404-718-6875

Funding Mechanism Type: ☐ Contract
☐ Cooperative Agreement
☐ Grant
Announcement #: Task order # 75D301-19-F-06983 Contract #: GS00F01CA

☐ Task/Purchase Order

☐ Other

II. Determination Conditions
To determine a project’s PRA applicability, record responses to the below conditions (Please Check).
1. Does the proposed activity obtain, cause to be obtained, solicit, or require the disclosure to CDC/ATSDR or a third party information by or for
CDC/ATSDR? In other words, will CDC/ATSDR require the collection, retention, or disclosure of information? ☐ Yes ☐ No
2. Does the proposed collection entail identical questions posed to, or identical reporting, recordkeeping, or
☐ Yes ☐ No
disclosure requirements imposed on or requesting the same information from ten (10) or more persons?
☐ Yes ☐ No
3. Is the collection of information conducted by CDC/ATSDR (will CDC/ATSDR collect the information)?
☐
Yes ☐ No
4. Is the collection of information sponsored by CDC/ATSDR?
5. If applicable, is this collection of information waived by the
National Childhood Vaccine Injury Act [Public Law 99-660, section 321-Title III]?
☐ Yes ☐ No
III. CIO Determination Decision (Please Check)
☐
OMB/PRA Clearance Required, as proposed activity constitutes a collection of information - (If “Yes” response provided for items 1-2 and for
either item 3 or 4 in the previous section)
☐
OMB/PRA Clearance Not Required – Per 5. C.F.R. 1320.3(h), the following PRA exemption/exclusion category applies to this collection of
information:
OMB/PRA Clearance Not Required – An active Information Collection Request for this activity has already been approved by OMB.
Title:
OMB Number:
Expiration Date:
☐
OMB/PRA Clearance Not Required – (If a “No” response provided for items 1 or 2 or if a “No” response for items 3 and 4 in the previous section)
☐
OMB/PRA Clearance Not Required – The PRA requirement waived by the National Childhood Vaccine Injury Act [Public Law 99-660, section 321Title III].
IV. Proposed Project Dates: 08/01/2022
to 08/31/2023
☐

V. Proposed Project Activities
If applicable, indicate the type of Information Collection Instrument/Activity proposed for use (Check all that apply):
☐ Mail-back Questionnaire ☐ On-site Questionnaire ☐ Personal Interview ☐ Telephone Survey ☐ Testing/Assessment Form
☐ Web-based Survey ☐ Focus Groups ☐ Record Abstractions ☐ Performance Report ☐ Evaluation ☐ Observation
☐ Application ☐ Comment Card ☐ Discussion Group ☐ Eligibility Form ☐ Audit Form ☐ Workshop ☐ Peer Review
☐ Report ☐ Reporting Form ☐ Diary ☐ Log ☐ Journal ☐ Inspection Form ☐ Usability Test ☐ Consents
☐ Acknowledgments ☐ Card Sorts ☐ Any other means of requesting information from 10 or more respondents (Explain):

☐ N/A
CDC 0.1490 (E), May 2014, CDC Adobe Acrobat 10.1, S508 Electronic Version, May 2014

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VI. Project Abstract/Summary (Provide justification by describing project’s purpose, objectives, funding conditions/intent, and
scope of Federal involvement):
The goal of this formative research study is to understand the extent to which a lesbian, gay, bisexual, transgender, and
queer/questioning (LGBTQ) inclusivity toolkit, designed for district- and school-level staff, supports the adoption and implementation of
strategies to create safe and supportive school environments for students with LGBTQ identities in high school (grades 9-12).
The study will explore the extent to which: (1) the LGBTQ inclusivity toolkit supports districts/high schools in identifying areas for
improvement in current LGBTQ inclusivity efforts, (2) the toolkit helps districts/high schools implement new or strengthen existing
strategies, (3) districts/high schools are able to diffuse policies/practices from the district to school-level implementation, (4) using toolkit
strategies changes awareness of and support for LGBTQ inclusivity and school climate across the district and select high schools, and
(5) the toolkit assists in incorporating LGBTQ inclusivity strategies in district and school-level diversity, equity, and inclusion (DEI) efforts.
The study will also explore usability, feasibility, and acceptability information provided by district and school-level staff using the draft
LGBTQ inclusivity toolkit to help inform revisions following the pilot study. The study will use a mixed-methods evaluation design with
participation from three U.S. school districts during the 2022-2023 academic year. Two participating school districts will each select two
high schools (grades 9-12), with one high school in each district serving as an intervention site and one high school in each district
serving as a comparison site for the outcome evaluation during the study; the remaining school district will select one high school for a
process evaluation. All three districts will receive the LGBTQ inclusivity toolkit and district and school-level staff will participate in action
planning, implementation, and data collection activities. To meet study objectives, two school districts will participate in a full outcome
evaluation, while the remaining school district will participate in process evaluations. The full outcome evaluation sites will include the
following information collections: 1) pre-post qualitative school climate interviews with district and school staff, 2) pre-post quantitative
self-report surveys with school staff, 3) monthly progress reports on toolkit implementation, and 4) post-pilot feedback interviews. The
process evaluation sites will include 1) pre-post qualitative school climate interviews with district and school staff, 2) monthly progress on
and 3) post-pilot feedback interviews.

VII. For determinations of “PRA Not Applicable” and “PRA Exemption/Exclusion Requested”, please provide a brief summary to
support the decision:
OMP PRA is applicable. Program is submitted an ICR.

VIII. CIO-PRA Oversight Official/Representative Certification Statement

On behalf of this project, I certify that this determination decision is in accordance with 5 CFR Part 1320.

Constance
Bonds -S

Digitally signed by
Constance Bonds -S
Date: 2022.05.17 14:58:16
-04'00'

OMB PRA Coordinator
Title

Signature
(FOR ICRO USE ONLY)
Audit Findings:

Selected for Audit?:

☐ OMB/PRA Clearance Not Required

☐ Yes

Signature

☐ No

☐ OMB/PRA Clearance Required

ICRO Desk Officer: Name (Last, First)
ICRO Chief

05/17/2022
Date

CDC ID No. 0920-22

CDC E-mail:
☐ Concur

Phone No.:

☐ Non-concur

03/29/2014
Date

CDC 0.1490 (E), May 2014, CDC Adobe Acrobat 10.1, S508 Electronic Version, May 2014

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