Targetted Race and Ethnicity Survey

ICR 199502-0938-002

OMB: 0938-0674

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
114138 Migrated
ICR Details
0938-0674 199502-0938-002
Historical Active
HHS/CMS
Targetted Race and Ethnicity Survey
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 05/08/1995
Retrieve Notice of Action (NOA) 02/07/1995
Approved for use through 3/96 under the condition that HCFA amends the Privacy Act statement so that it fully complies with 5 U.S.C. 552 a (e)(3) and considers data sharing with other interested Federal agencies as discussed in the Benefits Systems Review Team meetings. Such sharing must have accompanying agency commitments that encourage sharing of data with assurances that the information would only be used for consistent purposes and would not be available for subsequent release. In particular, 5 U.S.C. 552 a (e) (3) requires that the Privacy Act statement describes: 1) the purpose of the collection; 2) whether it is mandatory or voluntary; 3) the authority for such a collection; 4) the routine uses of the information; 5) the implications to the respondent for not complying; and 6) the computer matching that will be applied. Prior to committing to such matching (i.e. with other Federal agencies) HCFA may need to amend its Sytems of Records notice. HCFA should share its revised Privacy Act statement and Systems of Records notice with OMB and obtain its concurrence prior to proceeding with this survey.
  Inventory as of this Action Requested Previously Approved
03/31/1996 03/31/1996
1,800,000 0 0
60,000 0 0
0 0 0

This survey is being undertaken to improve the completeness of race and ethnicity information contained on the Medicare enrollment database. The information will help ensure health security for Medicare beneficiaries and assist in the enforcement of the Civil Rights Act of 1964. Respondents are Medicre beneficiaries whose current race/ethnicity annotation is 'unknown' or 'other' or who are likely to be Hispanic.

None
None


No

1
IC Title Form No. Form Name
Targetted Race and Ethnicity Survey HCFA-R-173

  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 1,800,000 0 0 1,800,000 0 0
Annual Time Burden (Hours) 60,000 0 0 60,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/07/1995


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