Adolescent Family Life Care Demonstration Project End of Year Care Template (EOYC)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0990 - suppt.st.Care and Prevention_revised_template_08 21 09.doc	Supporting Statement B	Uploaded 2009-08-23	Available
12291 IRB Approval.pdf	Supplementary Document	Uploaded 2009-08-23	Available
0990 - suppt.st.Care and Prevention_revised_template_08 21 09.doc	Supporting Statement A	Uploaded 2009-08-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
190515	Prevention Demonstration Project	Instruction	New
10433	Care Demonstration Project End of Year Care Template (EOYC)	Instruction	Modified

ICR Details

OMB Control No: 0990-0299	ICR Reference No: 200908-0990-009
Status: Historical Active	Previous ICR Reference No: 200602-0990-004
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Adolescent Family Life Care Demonstration Project End of Year Care Template (EOYC)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/31/2009
	Date Received in OIRA: 08/31/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	36 Months From Approved	12/31/2009
Responses	66	0	50
Time Burden (Hours)	4,290	0	106
Cost Burden (Dollars)	0	0	0

---

Abstract: The Adolescent Family Life Care Demonstration projects provide and evaluate services for pregnant and parenting adolescents. The end of Year Template will provide an outline and forms to report annually on program and evaluation services and outcomes.

---

Authorizing Statute(s): PL: Pub.L. 6 - 95 626 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 24013	05/22/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 44365	08/28/2009
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Care Demonstration Project End of Year Care Template (EOYC)
Prevention Demonstration Project

---

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	66	50	0	16	0	0
Annual Time Burden (Hours)	4,290	106	0	4,184	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There is a modest increase in burden requested because additional process evaluation questions are being added to the existing template, but this may be counterbalanced through the changes in the narrative portion. We are not increasing sample size for this data collection. These revisions will be used to facilitate program management.

---

Annual Cost to Federal Government: $101,904

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

---

Common Form ICR:  No

---

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: 08/31/2009

---