National Immunization Survey Evaluation Study

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 7317-110S Household Forms	Form	New	Available
Attachment A ACS Policy OMB 06_03_2009.pdf	Supplementary Document	Uploaded 2009-06-03	Available
NIS_Supporting_Statement_Evaluation_Study_06_03_2009_Part_B.rtf	Supporting Statement B	Uploaded 2009-06-03	Available
NIS_Supporting_Statement_Evaluation_Study_06_03_2009_Part_A_.rtf	Supporting Statement A	Uploaded 2009-06-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
188380	Provider Forms	Other-Frequently Asked Questions about HIPAA and the NIS	New
188379	Household Forms	Form	New

ICR Details

OMB Control No: 0607-0954	ICR Reference No: 200903-0607-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOC/CENSUS	Agency Tracking No:
Title: National Immunization Survey Evaluation Study
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: 06/04/2009
	Date Received in OIRA: 03/26/2009
Terms of Clearance: This collection is approved with the following terms of clearance: the Census Bureau will provide the report on the focus groups conducted with physicians and office staff and final copies of provider materials prior to initiating the provider survey, and Census and CDC will brief OMB on the results of this evaluation prior to making any agreement regarding the future use of the ACS frame for the National Immunization Survey (NIS). Approval of this evaluation study does not imply OMB approval for future use of the ACS frame by the NIS.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2010	09/30/2010
Responses	6,290	0	0
Time Burden (Hours)	1,596	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The National Immunization Survey (NIS) is an important tool for measuring vaccination coverage trends in the nation. The NIS Evaluation Study is a 1-time undertaking to explore how collaborating with the Census Bureau and using the American Community Survey (ACS) as the sampling frame for selecting eligible households could result in improving the utility of the current survey and in reducing data collection costs. The sample for the evaluation study will consist of households with age-eligible children, 19-35 months, located in Miami-Dade County, Duval County, and the balance of Florida. In order to render more accurate vaccination coverage estimates, health-care providers serving the cohort of children surveyed will also be contacted to obtain vaccination information.

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Authorizing Statute(s): US Code: 42 USC 306, 2102(a)(7) Name of Law: Public Health Service Act
   US Code: 13 USC 8 Name of Law: null
  

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 57320	10/02/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 11347	03/17/2009
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Household Forms	7317-110S, 7317-PPQ, 7317-110E, 7317-IBS, 7317-IB	Permission to Contact Immunization Provider - Spanish ,   Permission to Contact Immunization Provider - English ,   Information Collection Instrument Items Booklet ,   Immunization Survey Paper Questionnaire ,   Information Collection Instrument Items Booklet - Spanish
Provider Forms	7317-IHQ, 7317-110E, BC-1759 (P), 7317-IHQFG, 7317-DHAC, 7317-DHA, 7317-110S	HIPAA Accounting of Disclosure ,   Permission to Contact Immunization Provider - English ,   Immunization History Quest. Sample for SS Packet ,   Permission to Contact Immunization Provider ? Spanish ,   Immunization Study Special Sworn Status Form ,   HIPAA Accounting of Disclosure � Individual Child ,   Immunization History Questionnaire

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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	6,290	0	0	6,290	0	0
Annual Time Burden (Hours)	1,596	0	0	1,596	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: The collection is new.

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Annual Cost to Federal Government: $2,666,337

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)? No

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: 03/26/2009

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