Ryan White CARE Act Dental Reimbursement Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Ryan White CARE Act Dental Reimbursement Program	Form	Modified	Repair queued
Supporting Statement ss 0151 2011_FINAL.docx	Supporting Statement A	Uploaded 2011-03-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6384	Ryan White CARE Act Dental Reimbursement Program	Form	Modified

ICR Details

OMB Control No: 0915-0151	ICR Reference No: 201104-0915-002
Status: Historical Active	Previous ICR Reference No: 200805-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Ryan White CARE Act Dental Reimbursement Program
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/29/2011
	Date Received in OIRA: 04/14/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved	07/31/2011
Responses	70	0	80
Time Burden (Hours)	1,400	0	1,600
Cost Burden (Dollars)	0	0	0

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Abstract: Under the Ryan/White HIV/AIDS Treatment Modernization Act, accredited schools of dentistry, pre- and post-doctoral dental training programs, and dental hygiene education programs may apply for reimbursement of uncompensated costs for providing oral health care to HIV infected individuals. The Dental Services Form provides information on unreimbursed expenses and descriptions of selected program components in order to determine the reimbursement award amount and to report on provided services under the Act.

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Authorizing Statute(s): PL: Pub.L. 101 - 381 2601 Name of Law: Ryan White Comprehensive AIDS Resources Emergency (CARE) Act
   PL: Pub.L. 106 - 345 101-401 Name of Law: Ryan White CARE Act Amendments of 2000
   PL: Pub.L. 109 - 415 101-401 Name of Law: Ryan White HIV/AIDS Treatment Modernization Act of 2006
   PL: Pub.L. 111 - 87 2 Name of Law: Ryan White HIV/AIDS Treatment Extension Act of 2009
  

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:
	76 FR 5388	01/31/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 17139	03/28/2011
Did the Agency receive public comments on this ICR? No

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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
Ryan White CARE Act Dental Reimbursement Program	1	dental services form

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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	70	80	0	0	-10	0
Annual Time Burden (Hours)	1,400	1,600	0	0	-200	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $195,869

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 04/14/2011

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