HIV Prevention Program Evaluation and Monitoring System for Health Departments and Community-Based Organizations (PEMS)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
PEMS Data Variables and Values for Health Departments	Form and Instruction	Modified	Available
PEMS Data Variables and Values for CBOs	Form and Instruction	Modified	Available
PEMS Data Variables and Values for Health Departments	Form and Instruction	Modified	Available
Form No name HIV Test Form 1 new version	Form and Instruction	Modified	Available
Reverse Side of CTR Form with Codes	Form and Instruction	Modified	Available
Counseling, Testing and Referral Form	Form and Instruction	Modified	Available
PEMS Data Variables and Values for Health Departments	Form and Instruction	Modified	Available
Reverse Side of CTR Form with Codes	Form and Instruction	Modified	Available
Counseling, Testing and Referral Form	Form and Instruction	Modified	Available
PEMS Data Variables and Values for CBOs	Form and Instruction	Modified	Available
Background-forChangeForm83-C.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2007-10-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7165	PEMS Data Collection for Health Jurisdictions	Form and Instruction	Modified	PEMS Data Variables and Values for Health Departments
180698	PEMS Data Collection for Community-Based Organizations (Training)	Form and Instruction	Modified	PEMS Data Variables and Values for CBOs
180697	PEMS Data Collection for Health Jurisdictions (Training)	Form and Instruction	Modified	PEMS Data Variables and Values for Health Departments
180696	Counseling, Testing and Referral for Community-Based Organizations	Form and Instruction	Modified	HIV Test Form 1 new version
180696	Counseling, Testing and Referral for Community-Based Organizations	Form and Instruction	Modified	Reverse Side of CTR Form with Codes
180696	Counseling, Testing and Referral for Community-Based Organizations	Form and Instruction	Modified	Counseling, Testing and Referral Form
180695	PEMS Data Collection for Health Jurisdictions (CTR non-scan)	Form and Instruction	Modified	PEMS Data Variables and Values for Health Departments
180694	Counseling, Testing and Referral for Health Jurisdictions (CTR scan)	Form and Instruction	Modified	Reverse Side of CTR Form with Codes
180694	Counseling, Testing and Referral for Health Jurisdictions (CTR scan)	Form and Instruction	Modified	Counseling, Testing and Referral Form
180693	PEMS Data Collection for Community-Based Organizations	Form and Instruction	Modified	PEMS Data Variables and Values for CBOs

ICR Details

OMB Control No: 0920-0696	ICR Reference No: 200711-0920-003
Status: Historical Active	Previous ICR Reference No: 200706-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: HIV Prevention Program Evaluation and Monitoring System for Health Departments and Community-Based Organizations (PEMS)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/01/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/06/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	08/31/2010	08/31/2010
Responses	2,268	0	2,268
Time Burden (Hours)	181,512	0	181,512
Cost Burden (Dollars)	0	0	0

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Abstract: The HIV Prevention Program Evaluation and Monitoring System (PEMS) is an electronic, secure, browser-based system that will collect standardized HIV prevention program data from health departments and community-based organizations. The data will be used to monitor the delivery of prevention services data to clients and report on required program performance indicators.

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Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act
  

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 67354	11/21/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 28696	05/22/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Counseling, Testing and Referral for Community-Based Organizations	None, None, No name	Counseling, Testing and Referral Form ,   Reverse Side of CTR Form with Codes ,   HIV Test Form 1 new version
Counseling, Testing and Referral for Health Jurisdictions (CTR scan)	None, None	Counseling, Testing and Referral Form ,   Reverse Side of CTR Form with Codes
PEMS Data Collection for Community-Based Organizations	None	PEMS Data Variables and Values for CBOs
PEMS Data Collection for Community-Based Organizations (Training)	None	PEMS Data Variables and Values for CBOs
PEMS Data Collection for Health Jurisdictions	None	PEMS Data Variables and Values for Health Departments
PEMS Data Collection for Health Jurisdictions (CTR non-scan)	None	PEMS Data Variables and Values for Health Departments
PEMS Data Collection for Health Jurisdictions (Training)	None	PEMS Data Variables and Values for Health Departments

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ICR Summary of Burden

table that charts list 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	2,268	2,268	0	0	0	0
Annual Time Burden (Hours)	181,512	181,512	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $307,227

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 11/06/2007

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