Formative Research on Community-Level Factors that Promote the Primary Prevention of Adverse Childhood Experiences (ACEs) and Opioid Misuse Among Children, Youth, and Families in Tribal American India

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-20PJ Interview Discussion Guide	Form and Instruction	Unchanged	Available
Form 0920-20PJ Community Leaders or Service Providers	Form and Instruction	Unchanged	Available
Form 0920-20PJ Focus Group Discussion Guide	Form and Instruction	Unchanged	Available
Form 0920-20PJ Parents, Caregivers, and Young Adults	Form and Instruction	Unchanged	Repair queued
Form 0920-20PJ Interview - Focus Group Discussion Guide TE/TL/TH	Form and Instruction	Unchanged	Available
Form 0920-20PJ Tribal Elders/Tribal Leaders/Traditional Healers	Form and Instruction	Unchanged	Available
Form 0920-1351 Demographic Survey	Form and Instruction	Modified	Available
Form 0920-1351 Demographic Survey	Form and Instruction	Modified	Repair queued
Form 0920-20PJ Informed Consent	Form and Instruction	Unchanged	Available
Form 0920-20PJ Informed Consent	Form and Instruction	Unchanged	Repair queued
Form 0920-20PJ Telephone Screening	Form and Instruction	Unchanged	Available
Form 0920-20PJ Telephone Screening	Form and Instruction	Unchanged	Repair queued
BIRCH Changes to Attachment I Demographic Survey 5-12-2022.docx	Supplementary Document	Uploaded 2022-05-26	Repair queued
BIRCH Crosswalk Template Non Substantive OMB Changes 5-12-2022.xlsx	Supplementary Document	Uploaded 2022-05-25	Repair queued
BIRCH Change Request Memo OMB 0920-1351 5-12-2022.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-05-25	Repair queued
Attachment O_Study Flyer.docx	Supplementary Document	Uploaded 2021-05-11	Available
Attachment N_IRB Letter.pdf	Supplementary Document	Uploaded 2021-05-11	Repair queued
Attachment M_ PIA.pdf	Supplementary Document	Uploaded 2021-05-11	Repair queued
Attachment H List of local and national resources for participants.docx	Supplementary Document	Uploaded 2021-05-11	Repair queued
Attachment B_ Federal Register Notice.pdf	Supplementary Document	Uploaded 2021-05-11	Repair queued
Attachment A_ Authorizing Legislation.docx	Supplementary Document	Uploaded 2021-05-11	Repair queued
SSB Formative Research Tribal Communities_final.docx	Supporting Statement B	Uploaded 2021-05-11	Repair queued
SSA Formative Research Tribal Communities_final.docx	Supporting Statement A	Uploaded 2021-05-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
247307	Community Leaders or Service Providers	Form and Instruction	Unchanged	Interview Discussion Guide
247307	Community Leaders or Service Providers	Form and Instruction	Unchanged
247306	Parents, Caregivers, and Young Adults	Form and Instruction	Unchanged	Focus Group Discussion Guide
247306	Parents, Caregivers, and Young Adults	Form and Instruction	Unchanged
247305	Tribal Elders/Tribal Leaders/Traditional Healers	Form and Instruction	Unchanged	Interview - Focus Group Discussion Guide TE/TL/TH
247305	Tribal Elders/Tribal Leaders/Traditional Healers	Form and Instruction	Unchanged
247304	Demographic Survey	Form and Instruction	Modified	Demographic Survey
247304	Demographic Survey	Form and Instruction	Modified
247303	Informed Consent	Form and Instruction	Unchanged	Informed Consent
247303	Informed Consent	Form and Instruction	Unchanged
247302	Reminder Email/Letter	Other-Letter	Unchanged
247301	Confirmatin Email/Letter	Other-Letter	Unchanged
247300	Telephone Screening	Form and Instruction	Unchanged	Telephone Screening
247300	Telephone Screening	Form and Instruction	Unchanged
247298	Informational Letter	Other-Letter	Unchanged

ICR Details

OMB Control No: 0920-1351	ICR Reference No: 202205-0920-011
Status: Historical Active	Previous ICR Reference No: 202105-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1351-22FR
Title: Formative Research on Community-Level Factors that Promote the Primary Prevention of Adverse Childhood Experiences (ACEs) and Opioid Misuse Among Children, Youth, and Families in Tribal American India
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/10/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/26/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2024	10/31/2024	10/31/2024
Responses	920	0	920
Time Burden (Hours)	441	0	441
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request for non-substantive changes to the demographic survey related to the feedback received from the tribal communities engaged in the research study. The changes are outlined below and in Attachment I. Note that the request does not include changes to the currently approved burden and/or costs.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

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 128	07/02/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 26519	05/14/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Community Leaders or Service Providers	0920-20PJ	Interview Discussion Guide
Confirmatin Email/Letter
Demographic Survey	0920-1351	Demographic Survey
Informational Letter
Informed Consent	0920-20PJ	Informed Consent
Parents, Caregivers, and Young Adults	0920-20PJ	Focus Group Discussion Guide
Reminder Email/Letter
Telephone Screening	0920-20PJ	Telephone Screening
Tribal Elders/Tribal Leaders/Traditional Healers	0920-20PJ	Interview - Focus Group Discussion Guide TE/TL/TH

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	920	920	0	0	0	0
Annual Time Burden (Hours)	441	441	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $651,396

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.     Yes

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: 05/26/2022

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