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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
[NCHHSTP] DASH DEMO: LGBTQ Inclusivity Toolkit Evaluation 2022-2024
Agency IC Tracking Number:
0920-0840-23GM
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
n/a
Climate Interview Consent and Guide
Att 1_Staff Climate Interview Guide District & School Staff.docx
Yes
No
Fillable Fileable
Form and Instruction
n/a
School Staff Survey – Pre & Post Toolkit
Att 2_School Staff Survey in SurveyMonkey.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
n/a
Monthly Report Form
Att 3_Monthly Report Form.docx
Yes
Yes
Fillable Fileable
Form and Instruction
n/a
Post-Pilot Feedback Interview Guide
Att 4_Post-Pilot Feedback Inter Guide.docx
Yes
No
Fillable Fileable
Instruction
Att 10_Consent Form.docx
Yes
No
Fillable Fileable
Form and Instruction
n/a
School Staff Survey – Pre & Post Toolkit (Word)
Att 2_School Staff Survey&Consent.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
451
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
80 %
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
1,353
0
1,353
0
0
0
Annual IC Time Burden (Hours)
313
0
313
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
SSA
SSA-LGBTQ Inclusivity Toolkit Clean 6-27-23_final.docx
07/06/2023
SSB
SSB - LGBTQ Inclusivity Toolkit_final.docx
07/06/2023
Authorizing Legislation
Att 5_Auth Legislation.docx
07/06/2023
60 Day FRN
Att 6_60day_FRN.pdf
07/06/2023
ICF IRB Approval
Att 7_ICF IRB Approval_2021-248.pdf
07/06/2023
ICF IRB Determination
Att 7a_ICF Notice IRB Determination_10.26.22.pdf
07/06/2023
PIA
Att 8_PIA No PII.pdf
07/06/2023
Respondent Universe
Att 9_Respondent Universe_final.docx
07/06/2023
Project Determination
Project Determination_LGBTQ Toolkit_04.17.23.pdf
07/06/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.