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

Forms and Documents

Document Name	Status
ERSG Observational Program Implementation Fidelity Measure Form	Modified
ERSG Facilitator Program Implementation Fidelity Measure Form	Modified
Teen Dating Violence Support Group Evaluation Survey (Baseline Survey) Form	Modified
Form 2 Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment) Form	Modified
Teen Dating Violence Support Group Evaluation Survey (Completion Survey) Form	Modified
Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey) Form	Modified
ERSG OMB SSA 1.18.12 Clean Version.docx Supplementary Document	2012-01-19
ERSG OMB Change Request 1.18.12.docx Justification for No Material/Nonsubstantive Change	2012-01-19

IC Document Collections

IC ID	Document Title	Status
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

OMB Control No: 0920-0861	ICR Reference No: 201201-0920-007
Status: Historical Inactive	Previous ICR Reference No: 201110-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: A Controlled Evaluation of Expect Respect Support Groups (ERSG): Preventing and Interrupting Teen Dating Violence among At-Risk Middle and High School Students
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: Disapproved and continue	Conclusion Date: 01/25/2012
	Date Received in OIRA: 01/20/2012
Terms of Clearance: In accordance with section 3507(c)(1) of the Paperwork Reduction Act, this change request is not approved. Previous terms continue: CDC will maintain a strong oversight role in the evaluation of the intervention.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2013	08/31/2013	08/31/2013
Responses	2,232	0	2,232
Time Burden (Hours)	1,608	0	1,608
Cost Burden (Dollars)	0	0	0

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Abstract: A change is requested to allow ERSG facilitators to administer the survey, and not only trained data collectors.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Research and Investigation Generally
  

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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Teen Dating Violence Support Group Evaluation Survey (12-Month Follow Up Survey)	none	Completion and Follow-up Survey (12 month)
Teen Dating Violence Support Group Evaluation Survey (Completion Survey)	none	Completion Survey
Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)	2	Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)
Teen Dating Violence Support Group Evaluation Survey (Baseline Survey)	none	Att D - Baseline Survey
ERSG Facilitator Program Implementation Fidelity Measure	none	Facilitator Program Implementation Fidelity Measure
ERSG Observational Program Implementation Fidelity Measure	none	Observational Program Implementation Fidelity Measure

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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: $227,005

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

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? Uncollected

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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: 01/20/2012

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