National Evaluation of the DP18-1815 Cooperative Agreement Program: Category A, Diabetes Management and Type 2 Diabetes Prevention

Forms and Documents

Document Name	Status
National DPP Lifestyle Coach Interview Form and Instruction	New
National DPP Program Coordinator Interview Form and Instruction	New
National DPP Partner Site-Level Rapid Evaluation Survey Form and Instruction	New
DSMES Paraprofessional Team Member Interview Form and Instruction	New
DSMES Professional Team Member Interview Form and Instruction	New
DSMES Program Coordinator Interview Form and Instruction	New
DSMES Partner Site-Level Rapid Evaluation Survey Form and Instruction	New
National DPP Partner Site-Level Rapid Evaluation Nomination Form and Instruction	New
DSMES Partner Site-Level Rapid Evaluation Nomination Form and Instruction	New
Recipient-Led Evaluation Reporting Form and Instruction	New
Evaluation and Performance Measurement Plan (EPMP) Form and Instruction	New
Att 8d. Cat A Site Rapid Eval Fnl Rem Comm.docx Supplementary Document	2020-05-04
Att 8c. Cat A Site Rapid Eval Survey Rem Comm.docx Supplementary Document	2020-05-04
Att 8b. Cat A Site Rapid Eval Invit Comm.docx Supplementary Document	2020-05-04
Att 8a. Cat A Site Rapid Eval Pre Survey Comm_v02.docx Supplementary Document	2020-12-02
Att 7a. Inst Rev Brd App Det Pt B.pdf Supplementary Document	2020-05-04
Att 7a. Inst Rev Brd App Det Pt A.pdf Supplementary Document	2020-05-04
Att 6. 60-day FRN.pdf Supplementary Document	2020-05-04
Att 3f. Cat A 1815 Eval Gantt Chart.xlsx Supplementary Document	2020-05-04
Att 3e. Cat A 1815 Summ of Annual Resp_v06.docx Supplementary Document	2020-05-04
Att 3d. Cat A Crosswalk of Eval Comp_Data Coll.Tool.docx Supplementary Document	2020-05-04
Att 3c. 1815 Logic Model.docx Supplementary Document	2020-05-04
Att 3b.1815 Strat Prev_Control .docx Supplementary Document	2020-05-04
Att 3a. 1815 List of HD Awardees.docx Supplementary Document	2020-05-04
Att 2. Auth Leg Sec 301a of the PH Serv Act.pdf Supplementary Document	2020-05-04
Att 1. CDC-RFA-DP18-1815PPHF18.pdf Supplementary Document	2020-05-04
SSB_1815 Category A_v09.docx Supporting Statement B	2020-12-02
SSA_1815 Category A_v09.docx Supporting Statement A	2020-12-02

IC Document Collections

IC ID	Document Title	Status
241410	National DPP Lifestyle Coach Interview Form and Instruction	New
241409	National DPP Program Coordinator Interview Form and Instruction	New
241408	National DPP Partner Site-Level Rapid Evaluation Survey Form and Instruction	New
241407	DSMES Paraprofessional Team Member Interview Form and Instruction	New
241405	DSMES Professional Team Member Interview Form and Instruction	New
241404	DSMES Program Coordinator Interview Form and Instruction	New
241403	DSMES Partner Site-Level Rapid Evaluation Survey Form and Instruction	New
241402	National DPP Partner Site-Level Rapid Evaluation Nomination Form and Instruction	New
241401	DSMES Partner Site-Level Rapid Evaluation Nomination Form and Instruction	New
241400	Recipient-Led Evaluation Reporting Form and Instruction	New
241399	Evaluation and Performance Measurement Plan (EPMP) Form and Instruction	New

ICR Details

OMB Control No: 0920-1312	ICR Reference No: 201910-0920-009
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-19BHC
Title: National Evaluation of the DP18-1815 Cooperative Agreement Program: Category A, Diabetes Management and Type 2 Diabetes Prevention
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: 12/03/2020
	Date Received in OIRA: 05/15/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved
Responses	894	0	0
Time Burden (Hours)	1,084	0	0
Cost Burden (Dollars)	39,230	0	0

---

Abstract: The cooperative agreement supports state investments in implementing and evaluating evidence-based strategies to prevent and manage diabetes and cardiovascular disease (CVD). This information collection request focuses on activities conducted under Category A of the cooperative agreement: Diabetes Management and Type 2 Diabetes Prevention, The purpose of data collection is to evaluate how states are using funds and determine how those efforts are contributing to state, health system, or other organization level changes/outcomes related to diabetes.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 32185	07/05/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 29457	05/15/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 11

IC Title	Form No.	Form Name
Evaluation and Performance Measurement Plan (EPMP)	n/a	Evaluation and Performance Measurement Plan (EPMP)
Recipient-Led Evaluation Reporting	n/a	Category A Recipient-Led Annual Evaluation Report
DSMES Partner Site-Level Rapid Evaluation Nomination	n/a	DSMES Site-Level Rapid Evaluation - Site Nomination Form (screen shots)
National DPP Partner Site-Level Rapid Evaluation Nomination	n/a	National DPP Site-Level Rapid Evaluation - Site Nomination Form (screen shots)
DSMES Program Coordinator Interview	n/a	DSMES Site-Level Rapid Evaluation - Semi-Structured Interview Guide, Quality (Program) Coordinator
DSMES Professional Team Member Interview	n/a	DSMES Site-Level Rapid Evaluation - Semi-Structured Interview Guide, Professional Team Members
National DPP Partner Site-Level Rapid Evaluation Survey	n/a	National DPP Site-Level Rapid Evaluation - Survey Questionnaire
DSMES Paraprofessional Team Member Interview	n/a	DSMES Site-Level Rapid Evaluation - Semi-Structured Interview Guide, Paraprofessional Team Members
National DPP Program Coordinator Interview	n/a	National DPP Rapid Evaluation Interview Guide - Program Coordinator
National DPP Lifestyle Coach Interview	n/a	National DPP Site-Level Rapid Evaluation - Semi-Structured Interview Guide, Lifestyle Coach
DSMES Partner Site-Level Rapid Evaluation Survey	n/a	DSMES Site Survey Questionnaire

---

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	894	0	0	894	0	0
Annual Time Burden (Hours)	1,084	0	0	1,084	0	0
Annual Cost Burden (Dollars)	39,230	0	0	39,230	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 information collection.

---

Annual Cost to Federal Government: $1,333,819

Does this IC contain surveys, censuses, or employ statistical methods? No

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.     Yes

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? No

---

Common Form ICR:  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:

(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: 05/15/2020

---