Community-based Organization (CBO) Monitoring and Evaluation Project (CMEP) of WILLOW (CMEP-WILLOW)

Forms and Documents

Document Name	Status
180-day Follow-up Survey Form	Modified
90-day Follow-up Interview Form	Modified
Form 3 Baseline Survey Form and Instruction	Removed
Form 1 Eligibility Screener Form and Instruction	Removed
att1_PHSAsect301.pdf Supplementary Document	2014-06-05
60-Day FRN.pdf Supplementary Document	2014-06-05
Attachment 2A_Nonsubstantive Public Comments.docx Supplementary Document	2014-06-05
SS-Part B.doc Supporting Statement B	2014-06-05
SS-Part A WILLOW rev aug 26.doc Supporting Statement A	2014-08-28

IC Document Collections

IC ID	Document Title	Status
198815	180-day Follow-up Interview--Grantee Instruction	Modified
198814	180-day Follow-up Survey Form	Modified
198813	90-day Follow-up Interview--Grantees Instruction	Modified
198812	90-day Follow-up Interview Form	Modified
198811	Baseline Survey--Grantees Other-Screen shot	Removed
198810	Baseline Survey Form and Instruction	Removed
198809	Eligibility Screener--Grantees Other-screen shot	Removed
198808	Eligibility Screener Form and Instruction	Removed

ICR Details

OMB Control No: 0920-0896	ICR Reference No: 201406-0920-006
Status: Historical Active	Previous ICR Reference No: 201108-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Community-based Organization (CBO) Monitoring and Evaluation Project (CMEP) of WILLOW (CMEP-WILLOW)
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 with change	Conclusion Date: 08/29/2014
	Date Received in OIRA: 06/18/2014
Terms of Clearance: This extension allows each site to continue using only the incentive levels that they already used for 90- and 180-day follow ups in their area. This approval should not be interpreted as a precedent for differential incentives.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	12 Months From Approved	08/31/2014
Responses	736	0	1,732
Time Burden (Hours)	200	0	358
Cost Burden (Dollars)	0	0	0

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Abstract: The Community-based Organization Monitoring and Evaluation Project of WILLOW serves to monitor changes in client's self-reported HIV risk behaviors and attitudes after participating in the Effective Behavioral Intervention (EBI) WILLOW as delivered by CDC-funded CBOs and to assess the fidelity of the delivery of WILLOW at CBOs. From October 2011 throuigh March 21, 2014, baseline surveys were conducted with 941 participants; 90 day follow up surveys were completed with 700 participants,and 180 day follow up surveys with 609 participants. We request an additional year of approval to complete follow up surveys for participants completing the intervention before 8/31/2014.

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Authorizing Statute(s): US Code: 42 USC 241 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 13653	03/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 33194	06/10/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Eligibility Screener	1	Eligibility Screener
Eligibility Screener--Grantees
Baseline Survey	3	Baseline Survey
Baseline Survey--Grantees
180-day Follow-up Survey	none, none	180 day Follow up Survey ,   180 day Follow up Survey - screenshots
90-day Follow-up Interview	none, none	90 day Follow up Survey ,   90 day Follow up Survey - screenshots
90-day Follow-up Interview--Grantees
180-day Follow-up Interview--Grantee

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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	736	1,732	0	-996	0	0
Annual Time Burden (Hours)	200	358	0	-158	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The reduction in burden is due to this extension request only including the remaining follow up surveys for the last group of participants to receive the intervention and the last data submissions from the grantees to CDC. The screeners and baseline surveys have been removed.

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Annual Cost to Federal Government: $755,325

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: 06/18/2014

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