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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
DASH Demo: Comprehensive Health Educator Core Knowledge and Skills Training (CHECKS) PD Pilot Study
Agency IC Tracking Number:
0920-0840-20CQ
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
0920-0840
Adolescent Growth and Development Survey
Att 2_Adolescent Growth and Development survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 2a_Adolescent Growth and Development_screenshot.pdf
No
Paper Only
Form
0920-0840
Assess and Adjust Survey
Att 3_Assess and Adjust survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 3a_Assess and Adjust_screenshot.pdf
No
Paper Only
Form
0920-0840
Basic Principles of Teaching Health Education Survey
Att 4_Basic Principles of Teaching HE_elearning survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 4a_ Basic Principles of Teaching Health Education_screenshots.pdf
No
Paper Only
Form
0920-0840
Culturally Responsive Health Education Classroom Survey
Att 5_Culturally Responsive survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 5a_Culturally Responsive Health Education Classroom_screenshot.pdf
No
Paper Only
Form
0920-0840
In-person Training Survey
Att 6_In-person training survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 6a_In-Person Training Evaluation_screenshot.pdf
No
Paper Only
Form
0920-0840
Micro Session Survey
Att 7_Micro session survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 7a_CHECKS_Micro Session Survey_screenshot.pdf
No
Paper Only
Form
0920-0840
Trauma Informed Approach Survey
Att 8_TIA elearning module survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 8a_E-Learning Trauma Informed Approach_screenshot.pdf
No
Paper Only
Form
0920-0840
Teacher Survey
Att 9_Teacher Survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 9a_Teacher tool_screenshots.pdf
No
Paper Only
Form
0920-0840
Student Survey
Att 10_Student Survey.pdf
Yes
Yes
Fillable Fileable
Other-Screenshots
Att 10a_Student Tool_screenthots.pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,800
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,800
0
1,800
0
0
0
Annual IC Time Burden (Hours)
662
0
662
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Invitation Email
Att 11_ CHECKS_Pilot_Invitation Email.pdf
02/23/2021
Reminder Email
Att 11a_CHECKS PD_PIlot_Reminder Email.pdf
02/23/2021
Teacher Consent
Att 12 CHECKS PD Pilot_Teacher Consent.pdf
02/23/2021
Student Assent
Att 13_ CHECKS PD Pilot_Student Assent Form.pdf
02/23/2021
Parental Consent
Att 14_CHECKS PD Pilot_Parental Consent Form.pdf
02/23/2021
IRB Approval
Att 15_IRB Approval.pdf
02/23/2021
Respondent Universe
Att 16_Respondent Universe.docx
02/23/2021
Consultants
Att 17_CHECKS PD Pilot_Consultants.docx
02/23/2021
PIA
Att 18_PIA_CHECKS_PD_Pilot.pdf
02/23/2021
SSA
SSA-CHECKS-3_9_21_Clean.pdf
03/10/2021
SSB
SSB-CHECKS_1_11_20.docx
02/25/2021
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.