OMB Worksheet Part I and II - NVDRS

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part I: Information Collection Request

This template is intended for staff without an ICRAS account. Please fill out and submit to the appropriate Operating Division to enter into ICRAS. The form mirrors the screens available in the ICRAS 4 system. To request an account to log into ICRAS.

Instructions for filling out the form are available at www.paperworkreduction.gov.

1. Agency/Subagency originating request: CDC

2. Title : The National Violent Deatlh Reporting System

3. Type of information collection (check one)

(See instructions)

New collection (Request for a new OMB Control Number)

x Extension without change of a currently approved collection

Revision of a currently approved collection

Reinstatement without change of a previously approved collection

Reinstatement with change of a previously approved collection

Nonmaterial or nonsubstantive change to a currently approved collection (formerly 83C)

Existing collection in use without and OMB Control Number

4. OCN: 0920-0607___________

5. Type of review requested (check one)

a. X Regular

b. Emergency - Approval requested by: / ___ /

c. Delegated

If Emergency, please attach justification.( 4000 characters maximum)

6. Requested expiration date (check one)

a. X Three years from approval date

b. Six Months from approval date (Maximum for Emergency reviews)

3. Other
   

Specify: / (mm/yy)
or Number of Months from Approval Date

7. Abstract (4000 characters maximum, attach additional sheets as necessary)

The purpose of this project is to continue the collection and reporting of state violent death information. The proposed state-based surveillance

system will collect data from violent deaths and will provide more detailed and timely information regarding violent deaths.. This system will use case

records held by medical examiners, corners, police and crime labs.

8. Authorizing Statute(s)

Public Law:

Congress Number	Sequence Number	Section	Name

US Code:

Title	Section	Name
42	241 (280 1-a)	General Powers and Duties of Public Health Service

Executive Order:

Number	Name

Statute:

Title	Subtitle

9. Associated Rulemaking Information Stage of Rulemaking (check one) Federal Register Citation

RIN: - a. Proposed Rule Volume 70 Page number ____66839________
Publication Date 11 / 03 /_2005___

b. Interim Final or Final Rule

For a Proposed Rule, OMB will not consider an ICR complete until the Notice of Proposed Rulemaking has been published.

For a Final Rule, please put the ICR reference number for the ICR reviewed at the proposed rule stage in Box 4.

For ICRs associated with Interim Final or Final rules that are not significant under EO

10. Federal Register Notices & Comments

Federal Register Citation

60-day Notice: Volume 70 Page number 66839 Publication Date 11 / 03 / 2005

30-day Notice: Volume Page number Publication Date / /

Did the Agency receive public comments on this ICR? _Yes X_No

Unless submitted as an Emergency or Associated with Rulemaking, OMB will not consider an ICR complete until the 30-day notice has been published.12866, please attach a draft of the Federal Register document.

11. Annual Cost to Federal Gov:

$ 424,000

14. Agency contact:

Name: Catina Conner

Phone: 404-639-4775

E-mail: [email protected]

12. Does this ICR contain surveys, censuses, or employ statistical methods?

Yes (Attach Part B of Supporting Statement) X No

13. Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?

Yes X No

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part I: Information Collection Request (continued)

Information Collection Budget (ICB)

If a change in burden is due to a Program Change Due to New Statute, identify the Citations for New Statutory Requirements:

Public Law:

Congress Number	Sequence Number	Section	Name

US Code:

Title	Section	Name
42	241	Public Service Act

Executive Order:

Number	Name

Statute:

Title	Subtitle

If Program Change is due to Agency Discretion, please categorize the reduction. Burden reduction from (select one):

a. Cutting Redundancy
b. Using Information Technology
c. Changing Regulations
d. Changing Forms
e. Miscellaneous Actions

If Program Change is due to Agency Discretion, please categorize the increase in burden. Burden increase caused by (select one):
a. Changing Regulations
b. Miscellaneous Actions

Explain the reasons for any program changes or adjustments reported; that is, provide a short statement how the reduction in burden was achieved or why the increase in burden occurred. (If you need more space, please provide a short summary here and elaborate in the Supporting Statement.) __This package is exactly the same as the previously package with the exception of an incerase in states collecting the data, which inturn has increased the burden by 20,000 hours annually.

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

This template is intended for staff without an ICRAS account. Please fill out and submit to the appropriate Operating Division to enter into ICRAS. The form mirrors the screens available in the ICRAS 4 system. To request an account to log into ICRAS.

Instructions for filling out the form are available at www.paperworkreduction.gov.

1. Title: The National Violent Death Reporting System (NVDRS)

2. Is this a Common Form?

3. Obligation to respond (check one)

4. Frequency of reporting (check all that apply)

Yes

No

a. Voluntary

b. Required to obtain or retain benefits

c. X Mandatory

a. Hourly (24 -7)

b. __ Hourly Bus (40 per week)

c. Daily (7 per week)

d. Daily Bus (5 per week)

e. X Weekly (52 per year)

f. Monthly

g. Yearly

h. Every Decade

i. Quarterly

j. Semi-annually

k. Biennially

l.___ Once

m. ___ occasionally

5. CFR Citation(s) for the information collection under review (if applicable).
   
   

Title _______ Part __________________ Section________________________

Title _______ Part __________________ Section________________________

Title _______ Part __________________ Section________________________

Title _______ Part __________________ Section________________________

6. Information Collection Instruments – Send all instruments along with the Part 2 form(s). If more than one Part 2 is completed make sure to identify which instruments are associated with which Part 2 form.

7. Federal Enterprise Architecture Business Reference Model (Select one Services for Citizens Line of Business and one Subfunction from its group)

Services for Citizens Line of Business	Subfunction
None
Community and Social Services___	Homeownership Promotion___ Community and Regional Development___ Social Services___ Postal Service___ None___
Correctional Activities___	Criminal Incarceration Criminal Rehabilitation None
Defense and National Security___	Strategic National and Theater Defense___ Operational Defense___ Tactical Defense___ None___
Disaster Management___	Disaster Monitoring and Predication___ Disaster Preparedness and Planning___ Disaster Repair and Restore___ Emergency Response___ None___
Economic Development___	Business and Industry Development___ Intellectual Property Protection___ Financial Sector Oversight___ Industry Sector Income Stabilization___ None___
Education___	Elementary, Secondary, and Vocational Education___ Higher Education___ Cultural and Historic Preservation___ Cultural and Historic Exhibition___ None___
Energy___	Energy Supply___ Energy Conservation and Preparedness___ Energy Resource Management___ Energy Production___ None___
Environmental Management___	Environmental Monitoring and Forecasting___ Environmental Remediation___ Pollution Prevention and Control___ None___
General Science and Innovation___	Scientific and Technological Research and Innovation___ Space Exploration and Innovation ___ None___
Health___	Illness Prevention___ Immunization Management___ Public Health Monitoring___ Health Care Services___ Consumer Health and Safety___ None___
Homeland Security___	Border and Transportation Security___ Key Asset and Critical Infrastructure Protection___ Catastrophic Defense___ None___
Income Security___	General Retirement and Disability___ Unemployment Compensation___ Housing Assistance___ Food and Nutrition Assistance___ Survivor Compensation___ None___
Intelligence Operations___	Intelligence Planning and Direction/Needs___ Intelligence Collection___ Intelligence Analysis and Production___ Dissemination___ None___
International Affairs and Commerce___	Foreign Affairs___ International Development and Humanitarian Aid___ Global Trade___ None___
Law Enforcement___	Criminal Apprehension___ Criminal Investigation and Surveillance___ Citizen Protection___ Crime Prevention___ Leadership Protection___ Property Protection___ Substance Control___ None___
Litigation and Judicial Activities___	Judicial Hearing___ Legal Defense___ Legal Investigation___ Legal Prosecution and Litigation___ Resolution Facilitation ___ None___
Natural Resources___	Water Resource Management___ Conservation, Marine and Land Management___ Recreational Resource Management and Tourism___ Agricultural Innovation and Services___ None___
Transportation___	Air Transportation___ Ground Transportation___ Water Transportation___ Space Operations___ None___
Workforce Management___	Training and Employment___ Labor Rights Management___ Worker Safety___ None___

See http://www.feapmo.gov for the Business Reference Model categories and definitions.

8. Privacy Act System of Records (if applicable)

Title:

Federal Register Citation: Volume ______70__ Page number _____66839_______ Publication date 11 / 03 /_2005___

9. Respondents

a. Total # 20

b. Small Entity # 0 _________

c. Percent Electronic __100%_________

Affected public (choose one)
a. Individuals or households

b. Private Sector
c. X State, Local, or Tribal Governments
d. Federal Government

(if Private Sector check all that apply)
a. Business or other for-profits
b. Not-for-profit institutions
c. Farms

10. Frequency: How often on average will each respondent respond to the Information Collection?

Number of Responses per Respondent __1000__________

Per (select the most appropriate time period for this collection)

a. Hour (24-7) - 8736 per year

b. Business Hour (40 per week) - 2080 per year

c. Day (7 per week) - 364 per year

d. Business Day (5 per week) - 260 per year

e. X Week - 52 per year

f. Month - 12 per year

g. Year

h. Decade .1 per year

i. Quarter - 4 per year

j. Half-Year - 2 per year

k. Biennial - 0.5 per year

Calculated: Annual Frequency =_____52___________ times a year (per respondent)

Calculated: Annual Number Of Responses = ______20,000___________ a year

11. Hour and Cost Burden Enter the hours and cost (per response) broken out by reporting, record keeping, and third-party disclosure.
	Time per Response	Hour per response	Annual Hour Burden	Cost per Response	Annual cost Burden
Reporting		2.5	2000
Record keeping
Third party disclosure
Total

12. Allocate the change in burden

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses
b. Annual Hour Burden	hours	hours	hours	hours	hours	hours
c. Annual Cost Burden	$	$	$	$	$	$