Center for States Evaluation Ancillary Data Collection

Forms and Documents

Document Name	Status
Form 1 Annual Assessment Update (8 systematic questions) Form and Instruction	New
Form 1 Assessment and Service Delivery State Lead Interviews-Supplemental Questions Form and Instruction	New
Form 1 Service Delivery and Tracking and Adjustment Observation-Group Debrief Form and Instruction	New
Form 1 Assessment Observation-Group Debrief Form and Instruction	New
Form 1 Tailored Services Practice Model Survey Form and Instruction	New
Form 1 Child Welfare Virtual Conference Exit Survey Form and Instruction	New
Form 1 Child Welfare Virtual Conference Registration Form Form and Instruction	New
Form 1 Child Welfare Virtual Conference Interview Guide Form and Instruction	New
Form 1 Child Welfare Virtual Conference Focus Group Form and Instruction	New
Form 1 Child Welfare Virtual Conference Session Surveys Form and Instruction	New
SUPPORTING STATEMENT_CBCS Evaluation Ancillary Data Collection_Section B_2-10-17.docx Supporting Statement B	2017-05-11
SUPPORTING STATEMENT_CBCS Evaluation Ancillary Data Collection_Section A_2-10-17.docx Supporting Statement A	2017-05-11

IC Document Collections

IC ID	Document Title	Status
226795	Annual Assessment Update (8 systematic questions) Form and Instruction	New
226794	Assessment and Service Delivery State Lead Interviews-Supplemental Questions Form and Instruction	New
226793	Service Delivery and Tracking and Adjustment Observation-Group Debrief Form and Instruction	New
226792	Assessment Observation-Group Debrief Form and Instruction	New
226791	Tailored Services Practice Model Survey Form and Instruction	New
226790	Child Welfare Virtual Conference Exit Survey Form and Instruction	New
226788	Child Welfare Virtual Conference Registration Form Form and Instruction	New
226787	Child Welfare Virtual Conference Interview Guide Form and Instruction	New
226786	Child Welfare Virtual Conference Focus Group Form and Instruction	New
226785	Child Welfare Virtual Conference Session Surveys Form and Instruction	New

ICR Details

OMB Control No: 0970-0501	ICR Reference No: 201705-0970-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/ACF	Agency Tracking No: ACYF
Title: Center for States Evaluation Ancillary Data Collection
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: 08/16/2017
	Date Received in OIRA: 05/11/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved
Responses	7,431	0	0
Time Burden (Hours)	672	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Center for States Evaluation Ancillary Data Collection: Information Collection Request Overview This ICR Summary Form covers two ICs: one from individuals and one from state and territorial governments. The estimated annual totals for the entire Information Collection Request are: $53,146.27 (Government Cost); 7,431 responses; 671.06 respondent burden hours; and $14,622.40 (Cost to Respondents). The Evaluation of the Child Welfare Capacity Building Collaborative is sponsored by the Children’s Bureau (CB) in the Administration on Children, Youth and Families (ACYF), Administration for Youth and Families (ACF), U.S. Department of Health and Human Services (DHHS) which seeks approval for the data collection instruments and procedures described herein. The proposed information collection is necessary to facilitate, track, monitor, and evaluate the activities of the Center for States, part of the Capacity Building Collaborative. The Collaborative includes three Federally funded centers (Center for States, Center for Tribes, and Center for Courts) that deliver national child welfare expertise and evidence-informed training and technical assistance services to State, Tribal, and Territorial public child welfare agencies and Court Improvement Programs (CIPs). The CB funded Centers’ collective goal is to build the capacities of State, local, Tribal child welfare systems to successfully undertake practice, organizational, and systemic reforms necessary to implement federal policies, meet federal standards, and achieve better outcomes for the children, youth and families they serve. Agencies that receive formula funding through the Child Abuse Prevention and Treatment Act, and titles IV-B and IV-E of the Social Security Act are eligible for technical assistance from the Children’s Bureau to support implementation of these programs, compliance with federal requirements, and improvement of outcomes. Data collected through this proposed information collection will be used to improve the development and design of the Center for States’ services, and evaluation findings with be shared with other providers and service recipients to increase knowledge about technical assistance strategies and approaches. Evaluation findings will also inform future decision making about the service delivery structure and federal resource allocation. The Center for States’ services are evaluated by both Center-specific evaluations and a Cross-Center Evaluation. The Center-specific evaluations are designed to collect data on Center-specific processes and outcomes. The Cross-Center Evaluation is designed to respond to a set of cross-cutting evaluation questions posed by the Children’s Bureau. Data sources for this “Center for States Evaluation Ancillary Data Collection” information collection include (1) Instruments to assess the quality and effectiveness of a Child Welfare Virtual Conference; (2) Instruments to assess state experience with Center tailored service delivery in relation to implementation of the Center’s evidence-informed Capacity Building Approach; and (3) questions asked as part of the Center for States Annual Assessment process. This OMB package represents the third in a series of submissions for the Capacity Building Collaborative and these instruments represent Center for States data collection that is necessary to supplement the evaluation activities being conducted by the Collaborative and the Cross-Center evaluation.

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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 229	11/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 20895	05/04/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
Child Welfare Virtual Conference Exit Survey	1	Vitual Conference Exit Survey
Annual Assessment Update (8 systematic questions)	1	Annual Assessment Update
Child Welfare Virtual Conference Session Surveys	1	Virtual Conference Session Surveys
Child Welfare Virtual Conference Registration Form	1	Virtual Conference Registration
Service Delivery and Tracking and Adjustment Observation-Group Debrief	1	Service Deliver and Tracking and Adjustment Observation
Assessment and Service Delivery State Lead Interviews-Supplemental Questions	1	Assessment and Service Delivery State Lead Interview
Child Welfare Virtual Conference Focus Group	1	Virtual Conference Focus Group Guide
Child Welfare Virtual Conference Interview Guide	1	Conference Interview Guide
Tailored Services Practice Model Survey	1	Tailored Services Practive Model Survey
Assessment Observation-Group Debrief	1	Assessment Observation - Group Debrief

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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	7,431	0	0	7,431	0	0
Annual Time Burden (Hours)	672	0	0	672	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 ICR

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Annual Cost to Federal Government: $53,146

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 05/11/2017

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