Behavioral Health Preventive Care Assissment Focus Group

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Data Entry Group-Behavioral Health Preventive Care	Form and Instruction	New	Available
Administrator Group-Behavioral Health Preventive Care	Form and Instruction	New	Repair queued
Form no form number Provider Group-Behavioral Health Preventive Care	Form and Instruction	New	Available
BHPC OMB Supporting Statement final dec 18 2008.doc	Supporting Statement A	Uploaded 2009-04-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
188810	Data Entry Group-Behavioral Health Preventive Care	Form and Instruction	New
188809	Administrator Group-Behavioral Health Preventive Care	Form and Instruction	New
188808	Provider Group-Behavioral Health Preventive Care	Form and Instruction	New

ICR Details

OMB Control No: 0917-0032	ICR Reference No: 200904-0917-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Behavioral Health Preventive Care Assissment Focus Group
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 without change	Conclusion Date: 04/20/2009
	Date Received in OIRA: 04/15/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2012	36 Months From Approved
Responses	90	0	0
Time Burden (Hours)	180	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The IHS goal is to raise the health status of the American Indian and Alaska Native people to the highest possible level by providing comprehensive health care and preventive health services. To support this mission, IHS uses the Government Performance and Results Act (GPRA) as one mechanism to assess quality of care among health programs in its network. IHS currently reports GPRA results for twenty-two clinical measures that fall into the categories of Diabetes, Dental, Immunizations, and Prevention. The prevention category includes three measures related to behavioral health preventive screenings: Alcohol Screening (to prevent Fetal Alcohol Syndrome), Depression Screening, and Domestic/Intimate Partner Violence Screening.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: U.S. 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:
	73 FR 23254	04/29/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 64959	10/31/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Provider Group-Behavioral Health Preventive Care	no form number	Provider Questions
Administrator Group-Behavioral Health Preventive Care	none	none
Data Entry Group-Behavioral Health Preventive Care	None	None

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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	90	0	0	90	0	0
Annual Time Burden (Hours)	180	0	0	180	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 collection.

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Annual Cost to Federal Government: $200,000

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)? 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: 04/15/2009

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