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

Forms and Documents

Document Name	Status
Form 0920-xxxx Att 6_Sample Instrument: Parent/Caregiver Survey Form	New
Form 0920-xxxx Att 4_Sample Instrument: Youth Pre/Post Questionnaire Form and Instruction	New
Form 0920-xxxx Att 3_Sample Instrument: Youth Questionnaire Form and Instruction	New
SSA_031418.docx Supporting Statement A	2018-04-10
SSB_020618.docx Supporting Statement B	2018-04-10
Att 12-Example Adult Consent Form.docx Supplementary Document	2018-04-10
Att 11-Example Youth Verbal Assent Language.docx Supplementary Document	2018-04-10
Att 10-Example Active Parental Consent Form.docx Supplementary Document	2018-04-10
Att 9-Example Passive Parental Consent Form.docx Supplementary Document	2018-04-10
Att 8-Example Student Survey Items.docx Supplementary Document	2018-04-10

IC Document Collections

IC ID	Document Title	Status
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

OMB Control No: 0920-1235	ICR Reference No: 201804-0920-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-18AF
Title: Assessments to Inform Program Refinement for HIV, other STD, and Pregnancy Prevention among Middle and High-School Aged Youth
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 without change	Conclusion Date: 06/01/2018
	Date Received in OIRA: 04/12/2018
Terms of Clearance: 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
Expiration Date	06/30/2019	12 Months From Approved
Responses	67,000	0	0
Time Burden (Hours)	57,584	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 42 USC Sec 301.241(a) Name of Law: Public Health Service Act
  

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:
	82 FR 51835	11/08/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 13750	03/30/2018
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Att 7_Sample Instrument: Parent Interview/Focus Group Guide
Att 3_Sample Instrument: Youth Questionnaire	0920-xxxx	Sample Instrument: Youth Questionnaire
Att 4_Sample Instrument: Youth Pre/Post Questionnaire	0920-xxxx	Sample Instrument: Youth Pre/Post Questionnaire
Att 5_Youth Interview/Focus Group Guide
Att 6_Sample Instrument: Parent/Caregiver Survey	0920-xxxx	Sample Instrument: Parent/Caregiver Survey

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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	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

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: This is a NEW Generic information collection request (ICR)>

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Annual Cost to Federal Government: $46,238

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 04/12/2018

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