Information Collection

[NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024

IC 260956 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⚠️ Notice: This information collection may be referencing outdated material.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
Climate Interview Consent and Guide [NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024	Form and Instruction
School Staff Survey – Pre & Post Toolkit [NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024	Form and Instruction
Monthly Report Form [NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024	Form and Instruction
Post-Pilot Feedback Interview Guide [NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024	Form and Instruction
School Staff Survey – Pre & Post Toolkit (Word) [NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024	Form and Instruction
Att 10_Consent Form.docx	Instruction
Climate Interview Consent and Guide Att 1_Staff Climate Interview Guide District & School Staff.docx	Form and Instruction
School Staff Survey – Pre & Post Toolkit Att 2_School Staff Survey in SurveyMonkey.pdf	Form and Instruction
Monthly Report Form Att 3_Monthly Report Form.docx	Form and Instruction
Post-Pilot Feedback Interview Guide Att 4_Post-Pilot Feedback Inter Guide.docx	Form and Instruction
School Staff Survey – Pre & Post Toolkit (Word) Att 2_School Staff Survey&Consent.docx	Form and Instruction
SSA-LGBTQ Inclusivity Toolkit Clean 6-27-23_final.docx SSA	IC Document
SSB - LGBTQ Inclusivity Toolkit_final.docx SSB	IC Document
Att 5_Auth Legislation.docx Authorizing Legislation	IC Document
Att 6_60day_FRN.pdf 60 Day FRN	IC Document
Att 7_ICF IRB Approval_2021-248.pdf ICF IRB Approval	IC Document
Att 7a_ICF Notice IRB Determination_10.26.22.pdf ICF IRB Determination	IC Document
Att 8_PIA No PII.pdf PIA	IC Document
Att 9_Respondent Universe_final.docx Respondent Universe	IC Document
Project Determination_LGBTQ Toolkit_04.17.23.pdf Project Determination	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024

Agency IC Tracking Number:

0920-0840-23GM

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Yes	No	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	No	Fillable Fileable
Instruction		Yes	No	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 451

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,353	1,353
Annual IC Time Burden (Hours)	313	313
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA		07/06/2023
SSB		07/06/2023
Authorizing Legislation		07/06/2023
60 Day FRN		07/06/2023
ICF IRB Approval		07/06/2023
ICF IRB Determination		07/06/2023
PIA		07/06/2023
Respondent Universe		07/06/2023
Project Determination		07/06/2023

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

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