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 201209-0920-009 · 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 Repair queued
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 (12-Month Follow Up Survey) Form Modified Repair queued
ERSG Change Request Memo 9.14.12.docx Justification for No Material/Nonsubstantive Change Uploaded 2012-09-26 Available
ERSG OMB SSA - 9.24.12 clean.docx Supporting Statement A Uploaded 2012-09-26 Available
IC Document Collections
IC IDCollectionTypeStatusForm
204304 ERSG Facilitator End of Year Qualitative Interview Other-Interview Guide New
204303 ERSG Facilitator Mid-Year Qualitative Interview Other-Interview Guide New
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
194251 Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form Modified
ICR Details
0920-0861 201209-0920-009
Historical Active 201110-0920-005
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 09/28/2012
Retrieve Notice of Action (NOA) 09/27/2012
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
2,248 0 2,232
1,622 0 1,608
0 0 0
CDC would like to add qualitative interviews with the Evaluation of Expect Respect Support Groups(ERSG) facilators in order to better understand the implementation process for ERSG.
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 2,248 2,232 0 16 0 0
Annual Time Burden (Hours) 1,622 1,608 0 14 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
CDC would like to add qualitative interviews with the Evaluation of Expect Respect Support Groups(ERSG) facilators in order to better understand the implementation process for ERSG.
$227,005
Yes Part B of Supporting Statement
Yes
No
No
No
Uncollected
Carol Walker 4046394773
  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.
09/27/2012