Information Collection

DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation

IC 254269 under ICR 202103-0920-001 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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

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 %

table that charts list of burden
	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

table that charts IC Documents
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.