Pilot Study for the National Children's Study (NICHD)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form C.10.5 Instruments	Form and Instruction	New	Available
Form C.9.4 Instruments	Form and Instruction	New	Available
Form A.2.3 Instruments	Form and Instruction	New	Available
Form A.2.1 Instruments	Form and Instruction	New	Available
Form C.9.3 Instruments	Form and Instruction	New	Available
Form A.3.3 Survey	Form and Instruction	New	Available
Form A.3.1 Survey	Form and Instruction	New	Available
Form A.2.3.m1 Survey	Form and Instruction	New	Available
Form A.2.3.L3 Survey	Form and Instruction	New	Available
Form A.2.3.j3 Survey	Form and Instruction	New	Available
Form A.2.3.j2 Survey	Form and Instruction	New	Available
Form A.2.3.j1 Survey	Form and Instruction	New	Available
Form A.2.3.i Survey	Form and Instruction	New	Available
Form A.2.3.i Survey	Form and Instruction	New	Available
Form A.2.3.f Survey	Form and Instruction	New	Available
Form A.2.3.b3 Survey	Form and Instruction	New	Available
Form A.2.2.e Survey	Form and Instruction	New	Available
Form A.2.2.d Survey	Form and Instruction	New	Available
Form A.2.2.b Survey	Form and Instruction	New	Available
Form A.2.2.a Survey	Form and Instruction	New	Available
Form A.1.3.b Survey	Form and Instruction	New	Available
Form A.2.3.f Survey	Form and Instruction	New	Available
Form A.2.2.c Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survery	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form A.1.1.c Survey	Form and Instruction	New	Available
Form A.1.1.a Survey	Form and Instruction	New	Repair queued
Form A.2.1.h Survey	Form and Instruction	New	Available
Form A.3.2 Survey	Form and Instruction	New	Available
Form A.2.3.L5 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form A.1.2.b Survey	Form and Instruction	New	Available
Form A.1.2.b Survey	Form and Instruction	New	Available
Form A.1.2.b Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form 1 Survey	Form and Instruction	New	Available
Form A.1.1.b Survey	Form and Instruction	New	Available
Form A.1.1.c Survey	Form and Instruction	New	Available
Form A.1.1.a2 Survey	Form and Instruction	New	Available
Form A.1.1.c Survey	Form and Instruction	New	Available
Form A.1.1.a1 Survey	Form and Instruction	New	Available
Form A.1.1.a2 Survey	Form and Instruction	New	Available
Appendix C Revised.pdf	Supplementary Document	Uploaded 2008-09-22	Available
Appendix B Revised.pdf	Supplementary Document	Uploaded 2008-09-22	Available
IRB Certifications.pdf	Supplementary Document	Uploaded 2008-09-09	Available
Itemized Burden.doc	Supplementary Document	Uploaded 2008-09-09	Available
NCS Supporting Statement B.doc	Supporting Statement B	Uploaded 2008-09-09	Available
C.13 Itemized Burden Estimate Tables.doc	Supplementary Document	Uploaded 2008-03-24	Available
Appendix C1.pdf	Supplementary Document	Uploaded 2008-02-28	Available
Appendix B.pdf	Supplementary Document	Uploaded 2008-02-14	Available
NCS Pilot - Westat IRB Approval Ltr - 2008-01-29.pdf	Supplementary Document	Uploaded 2008-02-06	Available
NCS Supporting Statement A.doc	Supporting Statement A	Uploaded 2008-09-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
184283	Child Care Providers	Form and Instruction	New	Instruments
184282	Community Leaders	Form and Instruction	New	Instruments
184281	Health Care Providers	Form and Instruction	New	Instruments
184281	Health Care Providers	Form and Instruction	New	Instruments
184281	Health Care Providers	Form and Instruction	New	Instruments
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184280	Fathers	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survery
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184279	Postnatal Activities - Mother and Children	Form and Instruction	New	Survey
184278	Birth Activities-Mother and Children	Form and Instruction	New	Survey
184278	Birth Activities-Mother and Children	Form and Instruction	New	Survey
184278	Birth Activities-Mother and Children	Form and Instruction	New	Survey
184278	Birth Activities-Mother and Children	Form and Instruction	New	Survey
184278	Birth Activities-Mother and Children	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Other-Results Letter	New
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184277	Pregnancy Activities	Form and Instruction	New	Survey
184276	Low Probability Women	Form and Instruction	New	Survey
184275	Moderate Probability Women	Form and Instruction	New	Survey
184274	High Probability Women w/o Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184273	High Probability Women w/Pre-pregnancy Visit	Form and Instruction	New	Survey
184272	Eligibility Screening	Form and Instruction	New	Survey
184271	Household Enumeration	Form and Instruction	New	Survey
184271	Household Enumeration	Form and Instruction	New	Survey
184271	Household Enumeration	Form and Instruction	New	Survey
184271	Household Enumeration	Form and Instruction	New	Survey
184271	Household Enumeration	Form and Instruction	New	Survey

ICR Details

OMB Control No: 0925-0593	ICR Reference No: 200803-0925-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: Pilot Study for the National Children's Study (NICHD)
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: 09/22/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2008
Terms of Clearance: The National Children's Study Pilot cohort is approved for the first three years with the following terms of clearance: NIH has agreed to continue to work with OMB regarding clearance of the items that are still in the developmental stage, particularly the Data Access and Confidentiality plan and the consent video. In addition, NIH has agreed to submit changes to forms, protocols, and design elements, including but not limited to those that undergo additional testing, through the regular PRA process. Most of these changes will qualify as nonsubstantive changes. NIH will provide the OIRA desk officer with quarterly updates on its progress in testing the many design- and protocol-related hypotheses embedded into this pilot study. These updates should focus on the progress NIH is making in obtaining sufficient sample sizes to allow addressing the pilot questions; the analysis of the data needed to address those hypotheses; the implications of those analyses for the feasibility of the design, protocol, and data quality of the full study; the timing of additional testing that might be necessary before finalizing the design of the full study. NIH will provide OIRA with an understanding of the implications of the pilot study results before it submits the full package to OMB for review under the PRA.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2011	36 Months From Approved
Responses	64,598	0	0
Time Burden (Hours)	13,797	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 7. Abstract (4000 characters maximum, attach additional sheets as necessary) The purpose of this data collection is to Pilot Test protocols, policies, and procedures for the National Children's Study (NCS) with the goal of improving the efficiency of study procedures and enhancing the subsequent implementation of the NCS. The NCS is a long-term cohort study of environmental influences on child health and development authorized under the Children's Health Act of 2000. This data collection will test procedures for population-based sampling and recruitment of pregnant women and women of child-bearing age, test study logistics, and estimates of subject burden, and evaluate data collection strategies including interviews and acquisition of biologic and environmental samples.

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Authorizing Statute(s): PL: Pub.L. 106 - 310 1004 Name of Law: Childrens Health Act of 2000
  

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:
	72 FR 65049	11/19/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 5857	01/31/2008
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 13

table that charts list of burden

IC Title	Form No.	Form Name
Birth Activities-Mother and Children	A.3.2, A.2.1.h, A.2.3.L5, A.1.1.a, A.1.1.c	Survey ,   Survey ,   Survey ,   Survey ,   Survey
Child Care Providers	C.10.5	Instruments
Community Leaders	C.9.4	Instruments
Eligibility Screening	A.1.1.b	Survey
Fathers	A.2.3.f, A.1.3.b, A.2.2.a, A.2.2.b, A.2.2.c, A.2.2.d, A.2.2.e, A.2.3.b3, A.2.3.f, A.2.3.i, A.2.3.i, A.2.3.j1, A.2.3.j2, A.2.3.j3, A.2.3.L3, A.2.3.m1, A.3.1, A.3.3	Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey
Health Care Providers	C.9.3, A.2.1, A.2.3	Instruments ,   Instruments ,   Instruments
High Probability Women w/Pre-pregnancy Visit	1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1	Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey
High Probability Women w/o Pre-pregnancy Visit	A.1.2.b	Survey
Household Enumeration	A.1.1.a2, A.1.1.a1, A.1.1.c, A.1.1.a2, A.1.1.c	Survey ,   Survey ,   Survey ,   Survey ,   Survey
Low Probability Women	A.1.2.b	Survey
Moderate Probability Women	A.1.2.b	Survey
Postnatal Activities - Mother and Children	1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1	Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survery ,   Survey ,   Survey ,   Survey ,   Survey
Pregnancy Activities	1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1	Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey

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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	64,598	0	0	64,598	0	0
Annual Time Burden (Hours)	13,797	0	0	13,797	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 new information collection request.

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Annual Cost to Federal Government: $35,000,000

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: 03/28/2008

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