State Medicaid Tobacco Coverage Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Att-2b. Summary of Public Comments.pdf	Supplementary Document	Uploaded 2009-01-16	Available
Att-2a. 60-day FRN.pdf	Supplementary Document	Uploaded 2009-01-16	Available
Att-1. Public Health Service Act.doc	Supplementary Document	Uploaded 2009-01-16	Available
Att-6. Cover Email for Feedback Report.doc	Supplementary Document	Uploaded 2009-01-16	Available
Att-5. Thank You Email for Survey.doc	Supplementary Document	Uploaded 2009-01-16	Available
Att-4. Cover Email for Survey.doc	Supplementary Document	Uploaded 2009-01-16	Available
Att-3b. Proposed Changes to Tobacco Survey.doc	Supplementary Document	Uploaded 2009-01-16	Available
0691_SS-A_011609.doc	Supporting Statement A	Uploaded 2009-01-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7160	State Medicaid Tobacco Coverage Survey	Other-WORD	Modified

ICR Details

OMB Control No: 0920-0691	ICR Reference No: 200902-0920-001
Status: Historical Active	Previous ICR Reference No: 200505-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: State Medicaid Tobacco Coverage Survey
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/10/2009
	Date Received in OIRA: 02/03/2009
Terms of Clearance: Approved consistent with confirmation with CMS that this data collection does not duplicate data collection efforts at CMS.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved
Responses	51	0	0
Time Burden (Hours)	26	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC requests OMB approval to reinstate data collection with changes concerning state Medicaid program coverage for tobacco dependence treatments including medications and counseling, along with information about the utilization of the Public Health Service Guideline, "Treating Tobacco Use and Dependence" in developing and implementing their coverage.

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Authorizing Statute(s): None

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:
	73 FR 55515	09/25/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 13	01/22/2009
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
State Medicaid Tobacco Coverage 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	51	0	0	51	0	0
Annual Time Burden (Hours)	26	0	0	26	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: CDC is requesting OMB approval to reinstate information collection for an additional three years with minor changes. There is no increase in burden, but there are new and revised questions, which will collect information about the recommendations made in the updated PHS clinical practice guideline issue May 2008, regarding coverage for combination therapies, smokeless tobacco use, and their familiarity with and use of the 2000 and 2008 PHS guideline.

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Annual Cost to Federal Government: $75,200

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: 02/03/2009

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