Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

Forms and Documents

Document Name	Status
TCU Organizational Readiness Survey Form	New
Organizational Readiness Survey Form	New
Clinical Process Improvement Survey Form	New
NOFAS Post-test Survey Form	New
NOFAS Pre-test Survey Form	New
NOFAS Webinar 3 month Survey Form	New
NOFAS Webinar Survey Form	New
Social Work and Family Physician Follow-up Survey Form	New
Social Work and Family Physician Post-training Survey Form	New
Social Work and Family Physician Pre-training Survey Form	New
Family Medicine Evaluation Form	New
FASD Training Evaluation Form	New
FASD Work Plan Form	New
FASD Toolkit User Survey Form	New
AAP Post-training Survey Form	New
AAP Pre-training Survey Form	New
AAP 6 Month Follow-up Survey Form	New
AAP 3 Month Follow-up Survey Form	New
Pediatricians Survey Form	New
Medical Assistants Change in Practice Survey Form	New
Medical Assistants Follow-up Survey - Academic Form	New
Medical Assistants Follow-up Survey Form	New
Medical Assistants Post-test Survey - Academic Form	New
Medical Assistants Post-test Survey Form	New
Medical Assistants Pre-test Survey - Academic Form	New
Medical Assistants Pre-test Survey Form	New
OBGYN Telecom Training Survey Form	New
OBGYN Informant Interview - Posttraining Form	New
OBGYN Informant Interview - Pretraining Form	New
OBGYN Training Event Evaluation Form	New
OBGYN Avatar Training Survey Form	New
OBGYN Provider Follow-up Form	New
OBGYN Standardized Patient Form	New
OBGYN Provider Skills Baseline Form	New
OBGYN Knowledge and Agency Form	New
Healthcare Organization Survey Form	New
Nursing Network Survey Form	New
Form nopne Nursing Organization Questionnaire Form	New
Nursing DSW Polling Form	New
Nursing Follow-up Training Survey Form	New
Nursing Post-training Survey Form	New
Nursing Pre-training Survey Form	New
DSW Report Form	New
FASD Core Training - 6 month follow-up Form	New
FASD Core Training Survey - Post-test Form	New
FASD Core Training Survey Pretest Form	New
M FASD Evaluation Working Group Members.docx Supplementary Document	2016-03-02
C Public Comments from 60 Day FRN.pdf Supplementary Document	2016-03-02
60 Day FRN_CDC-2015-0081-0001.pdf Supplementary Document	2016-03-02
B Average_ Annualized_Cost_to_the_Federal_Government_12222015.docx Supplementary Document	2016-03-02
A1 Section 301 of the Public Health Service Act.docx Supplementary Document	2016-03-02
SupportingStatementPartB_FASD_PICS_and_Partners_Revised02112016.docx Supporting Statement B	2016-03-02
SupportingStatementPartA_FASD_PICS_and_Partners_Revised02112016.docx Supporting Statement A	2016-03-02

IC Document Collections

IC ID	Document Title	Status
220433	TCU Organizational Readiness Survey Form	New
220432	Organizational Readiness Survey Form	New
220431	Clinical Process Improvement Survey Form	New
220430	NOFAS Post-test Survey Form	New
220429	NOFAS Pre-test Survey Form	New
220428	NOFAS Webinar 3 month Survey Form	New
220427	NOFAS Webinar Survey Form	New
220426	Social Work and Family Physician Follow-up Survey Form	New
220425	Social Work and Family Physician Post-training Survey Form	New
220423	Social Work and Family Physician Pre-training Survey Form	New
220422	Family Medicine Evaluation Form	New
220421	FASD Training Evaluation Form	New
220419	FASD Work Plan Form	New
220418	FASD Toolkit Focus Group Guide Other-Discussion Guide	New
220417	FASD Toolkit User Survey Form	New
220416	AAP Post-training Survey Form	New
220414	AAP Pre-training Survey Form	New
220412	AAP 6 Month Follow-up Survey Form	New
220411	AAP 3 Month Follow-up Survey Form	New
220410	Pediatricians Survey Form	New
220408	Medical Assistants Change in Practice Survey Form	New
220407	Medical Assistants Follow-up Survey - Academic Form	New
220405	Medical Assistants Follow-up Survey Form	New
220404	Medical Assistants Post-test Survey - Academic Form	New
220403	Medical Assistants Post-test Survey Form	New
220402	Medical Assistants Pre-test Survey - Academic Form	New
220401	Medical Assistants Pre-test Survey Form	New
220400	OBGYN Telecom Training Survey Form	New
220399	OBGYN Informant Interview - Posttraining Form	New
220398	OBGYN Informant Interview - Pretraining Form	New
220397	OBGYN Training Event Evaluation Form	New
220396	OBGYN Avatar Training Survey Form	New
220395	OBGYN Provider Follow-up Form	New
220394	OBGYN Standardized Patient Form	New
220392	OBGYN Provider Skills Baseline Form	New
220391	OBGYN Knowledge and Agency Form	New
220390	Healthcare Organization Survey Form	New
220389	Nursing Network Survey Form	New
220388	Nursing Organization Questionnaire Form	New
220387	Nursing Informant Interview Other-Interview Guide	New
220386	Nursing DSW Polling Form	New
220385	Nursing Follow-up Training Survey Form	New
220384	Nursing Post-training Survey Form	New
220383	Nursing Pre-training Survey Form	New
220382	High Impact Study - Informant Interview Other-Interview Guide	New
220381	HIgh Impact Study - Discussion Guide Other-Discussion Guide	New
220379	DSW Report Form	New
220378	FASD Core Training - 6 month follow-up Form	New
220377	FASD Core Training Survey - Post-test Form	New
220375	FASD Core Training Survey Pretest Form	New

ICR Details

OMB Control No: 0920-1129	ICR Reference No: 201603-0920-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15BEZ
Title: Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships
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: 08/04/2016
	Date Received in OIRA: 03/09/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved
Responses	31,577	0	0
Time Burden (Hours)	3,776	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goals of this project are to evaluate the collaboration between the Practice and Implementation Centers (PICs) and national partners organizations, and to evaluate the work of the PICs and partners.

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Authorizing Statute(s): US Code: 42 USC 241 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:
	80 FR 55362	09/15/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 11801	03/07/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 50

IC Title	Form No.	Form Name
High Impact Study - Informant Interview
HIgh Impact Study - Discussion Guide
Nursing Pre-training Survey	none	Nursing Pre-Training Survey
Nursing Follow-up Training Survey	none	Nursing Training Follow-up Survey
Nursing DSW Polling	none	Nursing DSW Polling
Nursing Organization Questionnaire	nopne	Nursing Organization Questionnaire
Nursing Network Survey	none	Nursing Network Survey
OBGYN Informant Interview - Posttraining	none	OBGYN Informant Interview - Posttraining
OBGYN Telecom Training Survey	none	OBGYN Telecom Training Survey
Medical Assistants Pre-test Survey	none	Medical Assistants Pre-test Survey
Medical Assistants Post-test Survey	none	Medical Assistants Post-test Survey
Medical Assistants Follow-up Survey - Academic	none	Medical Assistants Folow-up Survey - Academic
AAP Pre-training Survey	none	AAP Pre-training Survey
AAP Post-training Survey	none	AAP Pre-training Survey
NOFAS Pre-test Survey	none	NOFAS Pre-test Survey
FASD Core Training Survey Pretest	none	FASD Pre-training survey
FASD Core Training Survey - Post-test	none	FASD Post-training survey
FASD Core Training - 6 month follow-up	none	FASD Training Survey - follow-up
Nursing Informant Interview
DSW Report	none	DSW Report
Nursing Post-training Survey	none	Nursing Post-training Survey
Healthcare Organization Survey	none	Healthcare Organization Survey
OBGYN Provider Skills Baseline	none	OBGYN Provider Skills Baseline
OBGYN Provider Follow-up	none	OBGYN Provider Follow-up
OBGYN Informant Interview - Pretraining	none	OBGYN Informant Interview - Pretraining
Medical Assistants Post-test Survey - Academic	none	Medical Assistants Post-test Survey - Academic
Medical Assistants Follow-up Survey	none	Medical Assistants Follow-up Survey
AAP 3 Month Follow-up Survey	none	AAP 3 Month Follow-up Survey
FASD Toolkit Focus Group Guide
FASD Work Plan	none	FASD Work Plan
FASD Training Evaluation	none	FASD Training Evaluation
Social Work and Family Physician Pre-training Survey	none	Social Work and Family Physician Pre-training Survey
NOFAS Post-test Survey	none	NOFAS Post-test Survey
Organizational Readiness Survey	none	Organizational Readiness Survey
OBGYN Knowledge and Agency	none	OBGYN Knowledge and Agency
OBGYN Avatar Training Survey	none	OBGYN Avatar Training Survey
OBGYN Standardized Patient	none	OBGYN Standardized Patient
OBGYN Training Event Evaluation	none	OBGYN Training Event Evaluation
Medical Assistants Pre-test Survey - Academic	none	Medical Assistants Pre-test Survey - Academic
Medical Assistants Change in Practice Survey	none	Medical Assistants Change in Practice Survey
Pediatricians Survey	none	Survey of Pediatricians
AAP 6 Month Follow-up Survey	none	AAP 6 Month Follow-up Survey
FASD Toolkit User Survey	none	FASD Toolkit User Survey
Family Medicine Evaluation	none	Family Medicine Evaluation
Social Work and Family Physician Post-training Survey	none	Social Work and Family Physician Post-training Survey
Social Work and Family Physician Follow-up Survey	none	Social Work and Family Physician Follow-up Survey
NOFAS Webinar Survey	none	NOFAS Webinar Survey
NOFAS Webinar 3 month Survey	none	NOFAS Webinar 3 month Survey
Clinical Process Improvement Survey	none	Clinical Process Improvement Survey
TCU Organizational Readiness Survey	none	TCU Organizational Readiness 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	31,577	0	0	31,577	0	0
Annual Time Burden (Hours)	3,776	0	0	3,776	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 ICR.

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Annual Cost to Federal Government: $1,603,724

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: 03/09/2016

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