OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

A Controlled Evaluation of Expect Respect Support Groups (ERSG): Preventing and Interrupting Teen Dating Violence among At-Risk Middle and High School Students

ICR 201110-0920-005 · OMB 0920-0861 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
ERSG Observational Program Implementation Fidelity Measure Form Modified Available
ERSG Facilitator Program Implementation Fidelity Measure Form Modified Available
Teen Dating Violence Support Group Evaluation Survey (Baseline Survey) Form Modified Available
Form 2 Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment) Form Modified Repair queued
Teen Dating Violence Support Group Evaluation Survey (Completion Survey) Form Modified Available
Teen Dating Violence Support Group Evaluation Survey (18-Month Follow Up Survey) Form Removed Repair queued
Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form Modified Available
ERSG OMB SSA 9.15.11 Clean Version.docx Supplementary Document Uploaded 2011-10-11 Available
ERSG Change Request 9-27-11.docx Justification for No Material/Nonsubstantive Change Uploaded 2011-10-12 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
197246 ERSG Observational Program Implementation Fidelity Measure Form Modified
197245 ERSG Facilitator Program Implementation Fidelity Measure Form Modified
194255 Teen Dating Violence Support Group Evaluation Survey (Baseline Survey) Form Modified
194254 Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment) Form Modified
194253 Teen Dating Violence Support Group Evaluation Survey (Completion Survey) Form Modified
194252 Teen Dating Violence Support Group Evaluation Survey (18-Month Follow Up Survey) Form Removed
194251 Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form Modified
ICR Details
0920-0861 201110-0920-005
Historical Active 201104-0920-005
HHS/CDC
A Controlled Evaluation of Expect Respect Support Groups (ERSG): Preventing and Interrupting Teen Dating Violence among At-Risk Middle and High School Students
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 10/14/2011
Retrieve Notice of Action (NOA) 10/14/2011
Previous terms continue: Approved with the understanding that CDC will maintain a strong oversight role in the evaluation of the intervention.
  Inventory as of this Action Requested Previously Approved
08/31/2013 08/31/2013 08/31/2013
2,232 0 2,632
1,608 0 2,008
0 0 0
Changes requested include rewording some of the survey questions and instructions and eliminating the 18 month follow-up survey.
US Code: 42 USC 241 Name of Law: Research and Investigation Generally
  
None
Not associated with rulemaking
No
  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 2,232 2,632 0 -400 0 0
Annual Time Burden (Hours) 1,608 2,008 0 -400 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
CDC has decided to eliminate the 18-month follow-up survey resulting in a burden reduction of 400 hours.
$227,005
Yes Part B of Supporting Statement
Yes
No
No
No
Uncollected
Daniel Holcomb 770 488-4472 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/14/2011