Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence

Forms and Documents

Document Name	Status
Form No number Employee Survey Form and Instruction	Modified
Form No number Manager Survey Form and Instruction	Modified
SuppStatement_B_Extension_ Request_9-16-09.doc Supporting Statement B	2009-10-21
Appendix N_PUBLIC commentON FEDERAL REGISTER.htm Supplementary Document	2009-10-21
Appendix M_Extension Request 60-day Federal Register Notice.pdf Supplementary Document	2009-10-21
Appendix L_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document	2009-10-21
Appendix K_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document	2009-10-21
Appendix J _Workplace OMB Package_1.21.08.pdf Supplementary Document	2009-10-21
Appendix I_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document	2009-10-21
Appendix H_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document	2009-10-21
Appendix G_IPV_Workplace_OMB_Package_10_18_07.doc Supplementary Document	2009-10-21
Appendix F_IPV_Workplace_OMB_Package_10_21_07..pdf Supplementary Document	2009-10-21
Appendix D_IPV_Workplace.1.21.08.doc Supplementary Document	2009-10-21
Appendix C_IPV Workplace.1.21.08.doc Supplementary Document	2009-10-21
Appendix E_IPV_Workplace_OMB_Package_10_21_07.doc Supplementary Document	2009-10-21
Appendix B_IPV_Workplace._1.21.08.doc Supplementary Document	2009-10-21
Appendix A_ IPV workplace OMB Package_6.7.07.doc Supplementary Document	2009-10-21
SuppStatement_A_Extension_ Request_9-21-09.doc Supporting Statement A	2009-10-21

IC Document Collections

IC ID	Document Title	Status
183664	Employee Survey Form and Instruction	Modified
183663	Manager Survey Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0789	ICR Reference No: 200911-0920-002
Status: Historical Active	Previous ICR Reference No: 200802-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/30/2009
	Date Received in OIRA: 11/03/2009
Terms of Clearance: Previous terms of clearance remain in effect.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	3 Months From Approved	12/31/2009
Responses	3,000	0	3,000
Time Burden (Hours)	1,125	0	1,125
Cost Burden (Dollars)	0	0	0

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Abstract: Intimate partner violence (IPV) affects a substantial number of Americans, and there has recently been increasing recognition of the impact it has on the workplace. The purpose of the proposed evaluation is to document in detail the workplace IPV prevention activities delivered by the company, to determine the impact of these activities on short-term and long-term outcomes, and to determine the cost-effectiveness of the program.

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Authorizing Statute(s): US Code: 42 USC 301 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:
	74 FR 43138	08/26/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 54829	10/23/2009
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Manager Survey	No number	Manager Survey
Employee Survey	No number	No name

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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	3,000	3,000	0	0	0	0
Annual Time Burden (Hours)	1,125	1,125	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: $293,820

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

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: 11/03/2009

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