HHS Suppmental Form to the SF-424 (HHS 5161-1)

Forms and Documents

Document Name	Status
Form HHS 5161-1 HHS 5161-1 Form and Instruction	New
Attachment DCDC Form 0.113.pdf Supplementary Document	2007-05-24
5161-SS-2007 [5-24-2007].doc Supporting Statement A	2007-05-24

IC Document Collections

IC ID	Document Title	Status
180307	HHS 5161-1 Form and Instruction	New

ICR Details

OMB Control No: 0990-0317	ICR Reference No: 200705-0990-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: HHS Suppmental Form to the SF-424 (HHS 5161-1)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/23/2007
	Date Received in OIRA: 05/24/2007
Terms of Clearance: Per HHS request OMB waives the requirement to include the expiration date during this approval. In the next approval request HHS should plan to include both the OMB control number and the approval date on associated forms.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved
Responses	7,457	0	0
Time Burden (Hours)	42,691	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Office of the Secretary (OS) at the U.S. Department of Health and Human Services (HHS), on behalf of the other former Public Health Service (PHS) agencies, is requesting the transfer of the PHS 5161-1 form from the Center for Disease Control (CDC) to HHS. The data collection is currently being collected under CDC OMB Number 0920-0428. Once clearance is granted the PHS-5161-1 will be renamed the HHS-5161-1 form. HHS is requesting a 3-year extension under a new OMB number.

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Authorizing Statute(s): US Code: 42 USC 247D Name of Law: Disaster Assistance
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 9826	02/22/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 24312	05/02/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
HHS 5161-1	HHS 5161-1	HHS 5161-1

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ICR Summary of Burden

	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	7,457	0	0	7,457	0	0
Annual Time Burden (Hours)	42,691	0	0	42,691	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a a new data collection.

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Annual Cost to Federal Government: $57,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 05/24/2007

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