Federal Evaluation of Making Proud Choices! (MPC!

Forms and Documents

Document Name	Status
Attachment B_Sources Referenced for the Followup Survey_revised82017.docx Supplementary Document	2017-08-08
Attachment A_Question by Question Source Table for the Followup Survey_revised882017.docx Supplementary Document	2017-08-08
Attachment E_Analysis Plan.docx Supplementary Document	2017-05-02
Attachment D_Confidentiality Pledge.docx Supplementary Document	2017-05-02
Attachment C_Persons Consulted on Instrument Development and Analysis for the Followup Survey.docx Supplementary Document	2017-05-02
Attachment B_Sources Referenced for the Followup Survey.docx Supplementary Document	2017-05-02
Attachment A_Question by Question Source Table for the Followup Survey.docx Supplementary Document	2017-05-02
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
0990_0452_Supporting_Statement B_OMB_Passback_rev_82017.docx Supporting Statement B	2017-08-08
0990_0452_Supporting Statement_A_MPC_OMB_Passback_rev82017.docx Supporting Statement A	2017-08-08

IC Document Collections

IC ID	Document Title	Status
226561	Follow-up Survey for 15 months Other-survey	New
226560	Follow-up Survey for 9 months Other-survey	New
223271	Youth Focus Group Other-Protocol	Unchanged
223270	Program Fidelity Checklist Other-checklist	Unchanged
223269	Program Attendance Data Collection Protocol Other-attendance	Unchanged
223268	Staff Survey Other-survey	Unchanged
223267	Master Topic Guide for Staff Interviews Other-survey	Unchanged
223265	Baseline Survey of impact study participants Instruction	Unchanged

ICR Details

OMB Control No: 0990-0452	ICR Reference No: 201704-0990-005
Status: Historical Active	Previous ICR Reference No: 201606-0990-004
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Federal Evaluation of Making Proud Choices! (MPC!
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/15/2017
	Date Received in OIRA: 05/02/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved	01/31/2020
Responses	3,086	0	1,493
Time Burden (Hours)	1,393	0	596
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:
	82 FR 10364	02/10/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 18920	04/24/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Follow-up Survey for 9 months
Follow-up Survey for 15 months
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	3,086	1,493	0	1,593	0	0
Annual Time Burden (Hours)	1,393	596	0	797	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: OAH now seeks approval on a program change for the data collection associated with the administration of the 9 and 15 month follow-up survey instrument. This request will increase the total annual burden requested for the MPC! Evaluation from 595.8 hours to 1,392.3 hours.

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Annual Cost to Federal Government: $1,038,783

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: 05/02/2017

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