Testing Act Early Messages and Materials for "Learn the Signs. Act Early" - Phase II

Forms and Documents

Document Name	Status
Act Early Parent Intercept Interview Form	New
Act Early Parent Intercept Interview Screener Form	New
Act Early Focus Group Informed Consent Form	New
Parent Focus Group Screener Form	New
Attachment 10 project factsheet Rev 1_5_15.docx Supplementary Document	2015-01-07
Att 15_IRB Approval Letter.pdf Supplementary Document	2014-09-03
Attachment 10 project factsheet Rev 1_5_15.docx Supplementary Document	2015-01-07
Att 13_LTSAE Checklist.pdf Supplementary Document	2014-09-03
Att 12_LTSAE Booklet.pdf Supplementary Document	2014-09-03
Att 11_LTSAE Brochure.pdf Supplementary Document	2014-09-03
Att 8_Act Early Parent Intercept Interview Recruitment Script_v2.docx Supplementary Document	2014-09-03
Att 4_Act Early Parent Focus Group Recruitment Handout_v2.docx Supplementary Document	2014-09-03
Att 3 _Act Early Parent Focus Group Recruitment Poster_v2.docx Supplementary Document	2014-09-03
Att 2_60dy_FRN.pdf Supplementary Document	2014-09-03
Att 1_Applicable Laws or Regulations.docx Supplementary Document	2014-09-03
SupportingStmnt B_OMB Testing Act Early messages and materials_May1_Westat rev.docx Supporting Statement B	2014-09-03
SupportingStmnt A_OMB Testing Act Early messages and materials_v2_Westat rev_082614.docx Supporting Statement A	2014-09-03

IC Document Collections

IC ID	Document Title	Status
212933	Act Early Parent Intercept Interview Form	New
212932	Act Early Parent Intercept Interview Screener Form	New
212931	Act Early Parent Focus Group Moderator's Guide Instruction	New
212930	Act Early Focus Group Informed Consent Form	New
212929	Parent Focus Group Screener Form	New

ICR Details

OMB Control No: 0920-1041	ICR Reference No: 201409-0920-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 14AAO
Title: Testing Act Early Messages and Materials for "Learn the Signs. Act Early" - Phase II
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/12/2015
	Date Received in OIRA: 09/12/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	12 Months From Approved
Responses	280	0	0
Time Burden (Hours)	74	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The study seeks to gather feedback on "Act Early" messages and materials from parents/guardians of children age 5 or younger attending the selected six primary care practices recruited for this study (3 in the Baltimore, Maryland (MD)/Washington, DC metropolitan area and 3 in the Atlanta, Georgia (GA) metropolitan area). Focus groups followed by intercept interviews will be used to assess the potential impact or influence of the materials on parents' behavioral intentions regarding "acting early" to address concerns with their child's development.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: PHSA
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 28729	05/19/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 52341	09/03/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Act Early Parent Intercept Interview	None	Act Early Parent Interview- Word
Parent Focus Group Screener	None	Act Early Parent Focus Screener
Act Early Focus Group Informed Consent	None	Act Early Focus Group Informed Consent
Act Early Parent Focus Group Moderator's Guide
Act Early Parent Intercept Interview Screener	None	Act Early Parent Intercept Interview Screener Screenshot

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ICR Summary of Burden

	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	280	0	0	280	0	0
Annual Time Burden (Hours)	74	0	0	74	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New ICR

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Annual Cost to Federal Government: $88,263

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? No

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: 09/12/2014

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