Multidisciplinary Health Care Models for Women Sustainability Assessment Survey

Forms and Documents

Document Name	Status
0990-MHCMWS-Supporting Statement_9 10 09(v)2.docx Supporting Statement B	2009-09-25
0990-MHCMWS-Supporting Statement_9 10 09(v)2.docx Supporting Statement A	2009-09-25

IC Document Collections

IC ID	Document Title	Status
190917	Site Staff and Community Partners (Telephone Interview) Other-survey	New
190916	Key Site Staff (Web-based survey) Other-survey	New

ICR Details

OMB Control No: 0990-0356	ICR Reference No: 200910-0990-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Multidisciplinary Health Care Models for Women Sustainability Assessment Survey
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: 01/26/2010
	Date Received in OIRA: 10/02/2009
Terms of Clearance: This information collection request is approved. OMB notes that HHS is not requesting approval of the site visits through this collection. HHS will seek OMB approval for collecting information covered by the PRA separately for that portion of collection, if applicable.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2013	36 Months From Approved
Responses	96	0	0
Time Burden (Hours)	148	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected and analyzed through this assessment will be used by OWH to develop evidence-based practices to sustain successful and effective agency programs and initiatives. It also will be shared with other DHHS agencies to inform their efforts to sustain promising and effective initiatives. The assessment will provide empirical information on what factors enabled programs to continue to implement the goals of the MHMW program after funding ended.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: 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:
	74 FR 33257	07/10/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 47945	09/18/2009
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Key Site Staff (Web-based survey)
Site Staff and Community Partners (Telephone Interview)

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ICR Summary 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	96	0	0	96	0	0
Annual Time Burden (Hours)	148	0	0	148	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: $58,902

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: 10/02/2009

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