OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

ICR 202102-0920-003 · OMB 0920-1129 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-1129 TCU Organizational Readiness Survey Form and Instruction New Repair queued
Form 0920-1129 Social Work and Family Physicians 6 Month Follow-Up Form and Instruction New Repair queued
Form 0292-1129 Post-Test Treatment Across the Lifespan Form and Instruction New Repair queued
Form 0920-1129 Post-Test ND-PAE Form and Instruction New Repair queued
Form 0920-1129 Pre-Test ND-PAE Form and Instruction New Repair queued
Form 0920-1129 Post-Test Screening, Assessment, and Diagnosis Form and Instruction New Missing upstream
Form 0920-1129 Medical Assistants Change in Practice Survey Form and Instruction New Missing upstream
Form 0920-1129 Medical Assistants Post-Test Survey Form and Instruction New Available
Form 0920-1129 Key Informant Interviews with Champions Form and Instruction New Repair queued
Form 092-1129 Health Professionals Survey (Nursing) Form and Instruction New Repair queued
Form 0920-1129 FASD Core Training Survey Post-Test Form and Instruction New Repair queued
Form 0920-1129 Core Pre Test Form and Instruction New Repair queued
Form 0920-1129 Health Professionals Survey Form and Instruction New Missing upstream
TCU Organizational Readiness Survey Form Removed Repair queued
Organizational Readiness Survey Form Removed Repair queued
Clinical Process Improvement Survey Form Removed Repair queued
Form 0920-1129 FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation (previously NO FAS Post-Test Survey) Form and Instruction Removed Missing upstream
Form 0920-1129 FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation (previously NOFAS Pre-Test Survey) Form and Instruction Removed Repair queued
NOFAS Webinar 3 month Survey Form Removed Missing upstream
NOFAS Webinar Survey Form Removed Repair queued
Social Work and Family Physician Follow-up Survey Form Removed Repair queued
Social Work and Family Physician Post-training Survey Form Removed Repair queued
Social Work and Family Physician Pre-training Survey Form Removed Repair queued
Family Medicine Evaluation Form Removed Missing upstream
FASD Training Evaluation Form Removed Repair queued
FASD Work Plan Form Removed Available
FASD Toolkit User Survey Form Removed Repair queued
Form 0920-1129 AAP Post-Training Evaluation Survey (Pediatrics) Form and Instruction Removed Repair queued
Form 0920-1129 AAP Pre-Training Evaluation Survey (Pediatrics) Form and Instruction Removed Missing upstream
Form 0920-1129 AAP 6 Month Follow-up Evaluation Survey (Pediatrics) Form and Instruction Removed Repair queued
Form 0920-1129 AAP 3 Month Follow-up Survey (Pediatrics) Form and Instruction Removed Repair queued
Pediatricians Survey Form Removed Repair queued
Medical Assistants Change in Practice Survey Form Removed Repair queued
Medical Assistants Follow-up Survey - Academic Form Removed Repair queued
Medical Assistants Follow-up Survey Form Removed Missing upstream
Medical Assistants Post-test Survey - Academic Form Removed Repair queued
Medical Assistants Post-test Survey Form Removed Repair queued
Medical Assistants Pre-test Survey - Academic Form Removed Repair queued
Medical Assistants Pre-test Survey Form Removed Repair queued
OBGYN Informant Interview - Posttraining Form Removed Repair queued
OBGYN Informant Interview - Pretraining Form Removed Repair queued
Form 0920-1129 OBGYN FASD-SBI Training Event Evaluation Form and Instruction Removed Repair queued
Form 0920-1129 OBGYN Guided Brief Intervention Satisfactory Survey (previously OBGYN Avatar Training Satisfaction Survey) Form and Instruction Removed Repair queued
OBGYN Provider Follow-up Form Removed Missing upstream
OBGYN Standardized Patient Form Removed Repair queued
OBGYN Provider Skills Baseline Form Removed Repair queued
OBGYN Knowledge and Agency Form Removed Repair queued
Healthcare Organization Survey Form Removed Repair queued
Nursing Network Survey Form Removed Repair queued
Form nopne Nursing Organization Questionnaire Form Removed Repair queued
Nursing DSW Polling Form Removed Repair queued
Six-Month Follow-Up Training Survey (Nursing) Form Removed Repair queued
Pre-Training Survey (Nursing) Form Removed Missing upstream
Pre-Training Survey (Nursing) Form Removed Repair queued
DSW Report Form Removed Repair queued
FASD Core Training - 6 month follow-up Form Removed Repair queued
FASD Core Training Survey - Post-test Form Removed Repair queued
Form 0920-1129 FASD Core Training Survey Pre-test Form and Instruction Removed Repair queued
D3 Social Work & Family Physicians 6 Month Follow Up Survey_Web-based version.pdf Supplementary Document Uploaded 2021-02-05 Missing upstream
D2 Social Work & Family Physicians Pre-Training Survey_Web-based version.pdf Supplementary Document Uploaded 2021-02-05 Repair queued
D1 Medical Assistants Change in Practice Survey_Web-based version.pdf Supplementary Document Uploaded 2021-02-05 Repair queued
7. Att.A_Authorizing Language_A1 Section 301 of the Public Health Service Act_0920-1129.docx Supplementary Document Uploaded 2021-02-03 Repair queued
5. IRB Form_0920-1129 Improving FASD.pdf Supplementary Document Uploaded 2021-02-03 Repair queued
60Day FRN 101320.pdf Supplementary Document Uploaded 2021-02-03 Repair queued
30 Day FRN 012820.pdf Supplementary Document Uploaded 2021-02-03 Missing upstream
2. SupportingStatementPartB_0920-1129 Improving FASD 12 08 2020_30DayFRN.docx Supporting Statement B Uploaded 2021-02-03 Repair queued
1. SupportingStatementPartA_0920-1129 Improving FASD 12 8 2020.docx Supporting Statement A Uploaded 2021-02-03 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
245669 TCU Organizational Readiness Survey Form and Instruction New
245668 Social Work and Family Physicians 6 Month Follow-Up Form and Instruction New
245667 Social Work and Family Physicians Pre-Training Survey New
245666 Post-Test Treatment Across the Lifespan Form and Instruction New
245665 Pre-Test Treatment Across the Lifespan New
245664 Post-Test ND-PAE Form and Instruction New
245663 Pre-Test ND-PAE Form and Instruction New
245662 Post-Test Screening, Assessment, and Diagnosis Form and Instruction New
245661 Pre-Test Screening, Assessment, and Diagnosis New
245659 Medical Assistants Change in Practice Survey Form and Instruction New
245656 Medical Assistants Post-Test Survey Form and Instruction New
245653 Medical Assistants Pre-Test Survey New
245652 Key Informant Interviews with Champions Form and Instruction New
245650 Health Professionals Survey (Nursing) Form and Instruction New
245648 FASD Core Training Survey Post-Test Form and Instruction New
245559 Core Pre Test Form and Instruction New
245558 Health Professionals Survey Form and Instruction New
220433 TCU Organizational Readiness Survey Form Removed
220432 Organizational Readiness Survey Form Removed
220431 Clinical Process Improvement Survey Form Removed
220430 FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation (previously NO FAS Post-Test Survey) Form and Instruction Removed
220429 FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation (previously NOFAS Pre-Test Survey) Form and Instruction Removed
220428 NOFAS Webinar 3 month Survey Form Removed
220427 NOFAS Webinar Survey Form Removed
220426 Social Work and Family Physician Follow-up Survey Form Removed
220425 Social Work and Family Physician Post-training Survey Form Removed
220423 Social Work and Family Physician Pre-training Survey Form Removed
220422 Family Medicine Evaluation Form Removed
220421 FASD Training Evaluation Form Removed
220419 FASD Work Plan Form Removed
220418 FASD Toolkit Focus Group Guide Other-Discussion Guide Removed
220417 FASD Toolkit User Survey Form Removed
220416 AAP Post-Training Evaluation Survey (Pediatrics) Form and Instruction Removed
220414 AAP Pre-Training Evaluation Survey (Pediatrics) Form and Instruction Removed
220412 AAP 6 Month Follow-up Evaluation Survey (Pediatrics) Form and Instruction Removed
220411 AAP 3 Month Follow-up Survey (Pediatrics) Form and Instruction Removed
220410 Pediatricians Survey Form Removed
220408 Medical Assistants Change in Practice Survey Form Removed
220407 Medical Assistants Follow-up Survey - Academic Form Removed
220405 Medical Assistants Follow-up Survey Form Removed
220404 Medical Assistants Post-test Survey - Academic Form Removed
220403 Medical Assistants Post-test Survey Form Removed
220402 Medical Assistants Pre-test Survey - Academic Form Removed
220401 Medical Assistants Pre-test Survey Form Removed
220400 OBGYN Telecom Training Survey Other-WORD Removed
220399 OBGYN Informant Interview - Posttraining Form Removed
220398 OBGYN Informant Interview - Pretraining Form Removed
220397 OBGYN FASD-SBI Training Event Evaluation Form and Instruction Removed
220396 OBGYN Guided Brief Intervention Satisfactory Survey (previously OBGYN Avatar Training Satisfaction Survey) Form and Instruction Removed
220395 OBGYN Provider Follow-up Form Removed
220394 OBGYN Standardized Patient Form Removed
220392 OBGYN Provider Skills Baseline Form Removed
220391 OBGYN Knowledge and Agency Form Removed
220390 Healthcare Organization Survey Form Removed
220389 Nursing Network Survey Form Removed
220388 Nursing Organization Questionnaire Form Removed
220387 Nursing Informant Interview Other-Interview Guide Removed
220386 Nursing DSW Polling Form Removed
220385 Six-Month Follow-Up Training Survey (Nursing) Form Removed
220384 Pre-Training Survey (Nursing) Form Removed
220383 Pre-Training Survey (Nursing) Form Removed
220382 High Impact Study - Informant Interview Other-Interview Guide Removed
220381 HIgh Impact Study - Discussion Guide Other-Discussion Guide Removed
220379 DSW Report Form Removed
220378 FASD Core Training - 6 month follow-up Form Removed
220377 FASD Core Training Survey - Post-test Form Removed
220375 FASD Core Training Survey Pre-test Form and Instruction Removed
ICR Details
0920-1129 202102-0920-003
Received in OIRA 201707-0920-006
HHS/CDC 0920-1129
Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships
Reinstatement without change of a previously approved collection   No
Regular 02/08/2021
  Requested Previously Approved
36 Months From Approved
16,938 0
2,332 0
0 0
The purpose of this information collection is to assess and address the knowledge, attitude, skills and practice behaviors of healthcare professionals to prevent, identify, and treat fetal alcohol spectrum disorders (FASDs). Data collected will be used to inform the development of, and determine the effectiveness of, trainings and other resources for the prevention, identification, and treatment of FASDs. Needs assessment and training data will be collected either electronically, via paper/pencil, or web-based survey. Qualitative data collections will be conducted by phone or in-person.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  85 FR 64469 10/13/2020
86 FR 7396 01/28/2021
No
17
IC Title Form No. Form Name
Medical Assistants Post-Test Survey 0920-1129 B7 Medical Assistants Post-Test Survey
Post-Test Screening, Assessment, and Diagnosis 0920-1129 B10 Post-Test Screening, Assessment and Diagnosis
Pre-Training Survey (Nursing) none Nursing Pre-Training Survey
Six-Month Follow-Up Training Survey (Nursing) none Nursing Training Follow-up Survey
Organizational Readiness Survey none Organizational Readiness Survey
Pre-Training Survey (Nursing) none Nursing Post-training Survey
FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation (previously NO FAS Post-Test Survey) 0920-1129 FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation
Clinical Process Improvement Survey none Clinical Process Improvement Survey
High Impact Study - Informant Interview
Nursing DSW Polling none Nursing DSW Polling
TCU Organizational Readiness Survey none TCU Organizational Readiness Survey
FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation (previously NOFAS Pre-Test Survey) 0920-1129 FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation
NOFAS Webinar 3 month Survey none NOFAS Webinar 3 month Survey
OBGYN Provider Follow-up none OBGYN Provider Follow-up
Social Work and Family Physician Follow-up Survey none Social Work and Family Physician Follow-up Survey
OBGYN FASD-SBI Training Event Evaluation 0920-1129 OBGYN FASD-SBI Training Event Evaluation
OBGYN Informant Interview - Pretraining none OBGYN Informant Interview - Pretraining
OBGYN Knowledge and Agency none OBGYN Knowledge and Agency
Nursing Organization Questionnaire nopne Nursing Organization Questionnaire
Nursing Informant Interview
NOFAS Webinar Survey none NOFAS Webinar Survey
Medical Assistants Change in Practice Survey none Medical Assistants Change in Practice Survey
AAP 6 Month Follow-up Evaluation Survey (Pediatrics) 0920-1129 AAP Six-Month Follow-Up Evaluation Survey
Nursing Network Survey none Nursing Network Survey
Healthcare Organization Survey none Healthcare Organization Survey
OBGYN Provider Skills Baseline none OBGYN Provider Skills Baseline
Social Work and Family Physician Post-training Survey none Social Work and Family Physician Post-training Survey
OBGYN Guided Brief Intervention Satisfactory Survey (previously OBGYN Avatar Training Satisfaction Survey) 0920-1129 OBGYN Guided Brief Intervention Satisfaction Survey
Social Work and Family Physician Pre-training Survey none Social Work and Family Physician Pre-training Survey
Pediatricians Survey none Survey of Pediatricians
AAP 3 Month Follow-up Survey (Pediatrics) 0920-1129 AAP Three-month Follow-up Evaluation Survey
AAP Pre-Training Evaluation Survey (Pediatrics) 0920-1129 Academia Americana De Pediatria Encuesta De Evaluacion De Seguimento De 6 Meses
FASD Core Training - 6 month follow-up none FASD Training Survey - follow-up
DSW Report none DSW Report
OBGYN Standardized Patient none OBGYN Standardized Patient
OBGYN Informant Interview - Posttraining none OBGYN Informant Interview - Posttraining
OBGYN Telecom Training Survey 0920-1129 OBGYN Telecom Training Satisfaction Survey (TTS)
Medical Assistants Pre-test Survey none Medical Assistants Pre-test Survey
Medical Assistants Pre-test Survey - Academic none Medical Assistants Pre-test Survey - Academic
Medical Assistants Follow-up Survey - Academic none Medical Assistants Folow-up Survey - Academic
Family Medicine Evaluation none Family Medicine Evaluation
AAP Post-Training Evaluation Survey (Pediatrics) 0920-1129 Academia Americana De Pediatria Ciiestionario De Elaluacion Posterior A La Capacitacion
FASD Training Evaluation none FASD Training Evaluation
Medical Assistants Post-test Survey - Academic none Medical Assistants Post-test Survey - Academic
FASD Toolkit User Survey none FASD Toolkit User Survey
Key Informant Interviews with Champions 0920-1129 B5 Key Informant Interviews with Champions
Medical Assistants Pre-Test Survey
HIgh Impact Study - Discussion Guide
FASD Core Training Survey Post-Test 0920-1129 Core Post-Training Survey
Health Professionals Survey (Nursing) 092-1129 Health Professionals Survey_Nursing
Medical Assistants Change in Practice Survey 0920-1129 B8 Medical Assistants Change in Practice Survey
FASD Toolkit Focus Group Guide
FASD Work Plan none FASD Work Plan
Health Professionals Survey 0920-1129 Health Professionals Survey
Core Pre Test 0920-1129 Core Pre-Test Survey
FASD Core Training Survey - Post-test none FASD Post-training survey
Medical Assistants Post-test Survey none Medical Assistants Post-test Survey
Medical Assistants Follow-up Survey none Medical Assistants Follow-up Survey
FASD Core Training Survey Pre-test 0920-1129 FASD Prevention, Identification & Alcohol Screening Pre-Training Evaluation
Pre-Test Screening, Assessment, and Diagnosis
Pre-Test ND-PAE 0920-1129 B11 Pre-test ND-PAE
Post-Test ND-PAE 0920-1129 B12 Post-test ND-PAE
Pre-Test Treatment Across the Lifespan
Post-Test Treatment Across the Lifespan 0292-1129 B14 Post-Test Treatment Across Lifespan
Social Work and Family Physicians Pre-Training Survey
Social Work and Family Physicians 6 Month Follow-Up 0920-1129 B16 Social Work & Family Physicians Pre-Training SurveyWeb-based version
TCU Organizational Readiness Survey 0920-1129 B17 TCU Organizational Readiness Survey
  Total Request 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 16,938 0 0 16,938 -31,577 31,577
Annual Time Burden (Hours) 2,332 0 0 2,332 -3,748 3,748
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
CDC is requesting approval for 2,338 burden hours. This reinstatement is requesting a decreased burden time (previously 3709 hrs.). This change largely occurs due to the reduction in the number of instruments being used. The total number of data collection instruments has decreased by 33 instruments. This notice has a 30-day comment period; CDC is requesting a three-year approval.
$830,120
Yes Part B of Supporting Statement
    No
    No
No
No
No
No
Odion Clunis 770 488-0045 [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.
02/08/2021