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Federal forms, ICRs, and supporting documents

Information Collection Request

Assessments to Inform Program Refinement for HIV, other STD, and Pregnancy Prevention among Middle and High-School Aged Youth

ICR 201804-0920-006 · OMB 0920-1235 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-xxxx Att 6_Sample Instrument: Parent/Caregiver Survey Form New Available
Form 0920-xxxx Att 4_Sample Instrument: Youth Pre/Post Questionnaire Form and Instruction New Available
Form 0920-xxxx Att 3_Sample Instrument: Youth Questionnaire Form and Instruction New Available
SSA_031418.docx Supporting Statement A Uploaded 2018-04-10 Available
SSB_020618.docx Supporting Statement B Uploaded 2018-04-10 Available
Att 12-Example Adult Consent Form.docx Supplementary Document Uploaded 2018-04-10 Available
Att 11-Example Youth Verbal Assent Language.docx Supplementary Document Uploaded 2018-04-10 Repair queued
Att 10-Example Active Parental Consent Form.docx Supplementary Document Uploaded 2018-04-10 Available
Att 9-Example Passive Parental Consent Form.docx Supplementary Document Uploaded 2018-04-10 Repair queued
Att 8-Example Student Survey Items.docx Supplementary Document Uploaded 2018-04-10 Available
IC Document Collections
IC IDCollectionTypeStatusForm
231030 Att 7_Sample Instrument: Parent Interview/Focus Group Guide Other-Moderator Guide New
231029 Att 6_Sample Instrument: Parent/Caregiver Survey Form New
231027 Att 5_Youth Interview/Focus Group Guide Other-Discussion Guide New
231026 Att 4_Sample Instrument: Youth Pre/Post Questionnaire Form and Instruction New
231024 Att 3_Sample Instrument: Youth Questionnaire Form and Instruction New
ICR Details
0920-1235 201804-0920-006
Historical Active
HHS/CDC 0920-18AF
Assessments to Inform Program Refinement for HIV, other STD, and Pregnancy Prevention among Middle and High-School Aged Youth
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/01/2018
Retrieve Notice of Action (NOA) 04/12/2018
Approved with the understanding that any GenICs submitted that are out of scope will be returned and, if ultimately pursued, will go through the standard notice and comment process prior to resubmitting.
  Inventory as of this Action Requested Previously Approved
06/30/2019 12 Months From Approved
67,000 0 0
57,584 0 0
0 0 0
The goal of this generic ICR is to conduct qualitative and quantitative data collection from adolescents (ages 11-19) and their parents/caregivers for the purpose of needs assessment and program refinement for programs and services designed to prevent HIV, STDs, and pregnancy among middle and high school aged adolescents. Data will be used to improve program and service.
US Code: 42 USC Sec 301.241(a) Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  82 FR 51835 11/08/2017
83 FR 13750 03/30/2018
Yes
  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 67,000 0 0 67,000 0 0
Annual Time Burden (Hours) 57,584 0 0 57,584 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a NEW Generic information collection request (ICR)>
$46,238
Yes Part B of Supporting Statement
    No
    No
No
No
No
Uncollected
Thelma Sims 4046394771
  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.
04/12/2018