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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation
Agency IC Tracking Number:
0920-0840-22GM
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 and Instruction
0920-0840
Pre-Post School Staff Survey Monkey
Att 2_Sch Staff Survey in SurveyMonkey.pdf
Yes
Yes
Fillable Printable
Form and Instruction
0920-0840
LGBTQ Inclusivity Toolkit Demonstration Project Monthly Report Form
Att 3_LGBTQ Toolkit Monthly Report Form.docx
Yes
Yes
Fillable Fileable
Form and Instruction
0920-0840
LGBTQ Inclusivity Toolkit Demonstration Project Post-Pilot Feedback Interview Guide
Att 4_Post-Pilot Feedback Inter Guide.docx
Yes
Yes
Printable Only
Instruction
Att 1_District _School Climate Interview Guide v2.docx
No
Printable Only
Form and Instruction
0920-0840
Pre=Post School Staff Survey
Att 2_School Staff Survey.docx
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:
400
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
400
0
400
0
0
0
Annual IC Time Burden (Hours)
275
0
275
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Authorizing Legislation
Att 5_Auth Legislation.docx
06/22/2022
60dy FRN
Att 6_60day_FRN.pdf
06/24/2022
IRB Approval
Att 7_ICF IRB Approval_2021-248.pdf
06/24/2022
Pre-Post School Staff Survey Consent Form
Att 9_Consent_School Staff Survey.docx
06/24/2022
Pre-Post School Staff and District Climate Interview Consent Form
Att 10_Consent_District Climate Interv.docx
06/24/2022
Pre-Post School Staff and District Staff Climate Interview, School Level Staff Consent Form
Att 11_Consent_School Climate Interv.docx
06/24/2022
PIA Form_Signed
Att 8_PRA Form - Signed.pdf
06/24/2022
Post Pilot Feedback Interview Consent Form
Att 12_Consent_Post-Pilot Feedback Interv.docx
06/24/2022
Response Universe
Att 13_Respondent Universe.docx
06/24/2022
NCHHSTP Project Determination & Approval
NCHHSTP Project Determination_LGBTQ Toolkit_03.08.22.pdf
06/24/2022
SSA
SSA.docx
06/24/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.