Federal Evaluation of Making Proud Choices! (MPC!

Forms and Documents

Document Name	Status
Zief Susan_Certificate of Approval for Study# 2398 Panel Meeting# 354....pdf Supplementary Document	2017-01-17
30-dayFederal Register, Volume 81 Issue 163 (Tuesday, August 23, 2016).htm Supplementary Document	2016-08-30
60-dayFederal Register, Volume 81 Issue 91 (Wednesday, May 11, 2016).htm Supplementary Document	2016-08-30
Attachment H - Pretest Survey Memo.pdf Supplementary Document	2016-08-30
Attachment G_Analysis Plan.docx Supplementary Document	2016-08-30
Attachment F_Confidentiality Pledge.pdf Supplementary Document	2016-08-30
Attachment E_Youth Focus Groups ConsentAssent Forms.docx Supplementary Document	2016-08-30
Attachment D_Baseline Survey Consent Letters and Forms Youth Assent Form....docx Supplementary Document	2017-01-17
Attachment C_Persons Consulted.docx Supplementary Document	2016-08-30
Attachment B_Sources Referenced for the Baseline_revised.docx Supplementary Document	2016-08-30
Attachment A_Question by Question Source List_revised_8.22.16.docx Supplementary Document	2016-08-30
SS_B.docx Supporting Statement B	2016-08-30
MPC_SS_A_revised_MPR 011217_CLEAN.docx Supporting Statement A	2017-01-12

IC Document Collections

IC ID	Document Title	Status
223271	Youth Focus Group Other-Protocol	New
223270	Program Fidelity Checklist Other-checklist	New
223269	Program Attendance Data Collection Protocol Other-attendance	New
223268	Staff Survey Other-survey	New
223267	Master Topic Guide for Staff Interviews Other-survey	New
223265	Baseline Survey of impact study participants Instruction	New

ICR Details

OMB Control No: 0990-0452	ICR Reference No: 201606-0990-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Federal Evaluation of Making Proud Choices! (MPC!
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: 01/17/2017
	Date Received in OIRA: 08/30/2016
Terms of Clearance: Approved consistent with the understanding that this clearance covers only the baseline survey and accompanying fidelity assessments for the overall MPC collection. Federal collection activities pertaining to the 9 and 15 month follow-up surveys will be submitted to OMB for a separate PRA review under a New/Revision ICR request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved
Responses	1,493	0	0
Time Burden (Hours)	596	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: MPC; it includes the baseline survey instrument related to the impact study and instruments for the implementation and fidelity assessment. The evaluation will be conducted in 39 schools nationwide. The data collected from these instruments will be used to describe the characteristics of the study sample of youth, being used in the models for estimating program impacts, and provide a detailed understanding of program implementation.

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Authorizing Statute(s): None

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:
	81 FR 29282	05/11/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 57594	08/23/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Master Topic Guide for Staff Interviews
Program Fidelity Checklist
Baseline Survey of impact study participants
Staff Survey
Program Attendance Data Collection Protocol
Youth Focus Group

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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	1,493	0	0	1,493	0	0
Annual Time Burden (Hours)	596	0	0	596	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: New Collection

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Annual Cost to Federal Government: $500,100

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: 08/30/2016

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