DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation

Formative Research and Tool Development

OMB: 0920-0840

IC ID: 254269

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0840 DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation Form and Instruction
Att 1_District _School Climate Interview Guide v2.docx Instruction
0920-0840 Pre-Post School Staff Survey Monkey Att 2_Sch Staff Survey in SurveyMonkey.pdf Form and Instruction
0920-0840 LGBTQ Inclusivity Toolkit Demonstration Project Monthly Att 3_LGBTQ Toolkit Monthly Report Form.docx Form and Instruction
0920-0840 LGBTQ Inclusivity Toolkit Demonstration Project Post-Pil Att 4_Post-Pilot Feedback Inter Guide.docx Form and Instruction
0920-0840 Pre=Post School Staff Survey Att 2_School Staff Survey.docx Form and Instruction
Att 5_Auth Legislation.docx Authorizing Legislation IC Document
Att 6_60day_FRN.pdf 60dy FRN IC Document
Att 7_ICF IRB Approval_2021-248.pdf IRB Approval IC Document
Att 9_Consent_School Staff Survey.docx Pre-Post School Staff Survey Consent Form IC Document
Att 10_Consent_District Climate Interv.docx Pre-Post School Staff and District Climate Interview Consent Form IC Document
Att 11_Consent_School Climate Interv.docx Pre-Post School Staff and District Staff Climate Interview, School Level Staff Consent Form IC Document
Att 8_PRA Form - Signed.pdf PIA Form_Signed IC Document
Att 12_Consent_Post-Pilot Feedback Interv.docx Post Pilot Feedback Interview Consent Form IC Document
Att 13_Respondent Universe.docx Response Universe IC Document
NCHHSTP Project Determination_LGBTQ Toolkit_03.08.22.pdf NCHHSTP Project Determination & Approval IC Document
SSA.docx SSA IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation	Agency IC Tracking Number:	0920-0840-22GM

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0840	Pre-Post School Staff Survey Monkey	Att 2_Sch Staff Survey in SurveyMonkey.pdf	Yes	Yes	Fillable Printable
Form and Instruction	0920-0840	LGBTQ Inclusivity Toolkit Demonstration Project Monthly Report Form	Att 3_LGBTQ Toolkit Monthly Report Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0840	LGBTQ Inclusivity Toolkit Demonstration Project Post-Pilot Feedback Interview Guide	Att 4_Post-Pilot Feedback Inter Guide.docx	Yes	Yes	Printable Only
Instruction			Att 1_District _School Climate Interview Guide v2.docx	No		Printable Only
Form and Instruction	0920-0840	Pre=Post School Staff Survey	Att 2_School Staff Survey.docx	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	275	275
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Authorizing Legislation	Att 5_Auth Legislation.docx	06/22/2022
60dy FRN	Att 6_60day_FRN.pdf	06/24/2022
IRB Approval	Att 7_ICF IRB Approval_2021-248.pdf	06/24/2022
Pre-Post School Staff Survey Consent Form	Att 9_Consent_School Staff Survey.docx	06/24/2022
Pre-Post School Staff and District Climate Interview Consent Form	Att 10_Consent_District Climate Interv.docx	06/24/2022
Pre-Post School Staff and District Staff Climate Interview, School Level Staff Consent Form	Att 11_Consent_School Climate Interv.docx	06/24/2022
PIA Form_Signed	Att 8_PRA Form - Signed.pdf	06/24/2022
Post Pilot Feedback Interview Consent Form	Att 12_Consent_Post-Pilot Feedback Interv.docx	06/24/2022
Response Universe	Att 13_Respondent Universe.docx	06/24/2022
NCHHSTP Project Determination & Approval	NCHHSTP Project Determination_LGBTQ Toolkit_03.08.22.pdf	06/24/2022
SSA	SSA.docx	06/24/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.