Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 14 Quarterly_Report	Form and Instruction	New	Available
Form 15 Participant Information Form	Form and Instruction	New	Available
Form 14 Consent Form	Form and Instruction	New	Available
Form 13 Focus_Group_Social_Service	Form and Instruction	New	Available
Form 15 Participant Information Form	Form and Instruction	New	Available
Form 14 Consent Form	Form and Instruction	New	Available
Form 12 Focus_Group_Health_Provider	Form and Instruction	New	Available
Form 15 Participant Information Form	Form and Instruction	New	Available
Form 14 Consent Form	Form and Instruction	New	Available
Form 11 PN_Health_Administrator_Focus_Group	Form and Instruction	New	Available
Form 10 Cultural Competency	Form and Instruction	New	Available
Form 9 Clinic-Wide Measures	Form	New	Available
Form 7 Co-occuring Disorders	Form and Instruction	New	Available
Form 8 Clinical Measures	Form and Instruction	New	Available
Form 15 Participant Information Form	Form and Instruction	New	Available
Form 14 Consent Form	Form and Instruction	New	Available
Form 6 PN_Focus Group	Form and Instruction	New	Available
Form 4 Forms	Form and Instruction	New	Available
Form 5 Target Services Log	Form and Instruction	New	Available
Form 3 Patient Navigator Survey	Form and Instruction	New	Available
Form 2 VR_English_Self	Form and Instruction	New	Available
Form 1 Intake and Target	Form and Instruction	New	Available
Memo to OMBNov11_2011.doc	Supplementary Document	Uploaded 2011-12-06	Available
Supporting Statement Section BRev11152011.docx	Supporting Statement B	Uploaded 2011-12-06	Available
Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program - Authorizing Legislation.pdf	Supplementary Document	Uploaded 2011-05-31	Available
Supporting Statement Section Arev 11152011.docx	Supporting Statement A	Uploaded 2011-12-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198114	Quarterly Report	Form and Instruction	New	Quarterly_Report
198113	Social Service Provider Focus Group	Form and Instruction	New	Participant Information Form
198113	Social Service Provider Focus Group	Form and Instruction	New	Consent Form
198113	Social Service Provider Focus Group	Form and Instruction	New	Focus_Group_Social_Service
198112	Grantee Health Care Provider Focus Group	Form and Instruction	New	Participant Information Form
198112	Grantee Health Care Provider Focus Group	Form and Instruction	New	Consent Form
198112	Grantee Health Care Provider Focus Group	Form and Instruction	New	Focus_Group_Health_Provider
198111	Patient Navigator/Health System Administrator Focus Group	Form and Instruction	New	Participant Information Form
198111	Patient Navigator/Health System Administrator Focus Group	Form and Instruction	New	Consent Form
198111	Patient Navigator/Health System Administrator Focus Group	Form and Instruction	New	PN_Health_Administrator_Focus_Group
198110	Patient Navigator Cultural Competency Checklist	Form and Instruction	New	Cultural Competency
198109	Annual Clinic-Wide Clinical Performance Measures Report	Form	New	Clinic-Wide Measures
198108	Patient Medical Record and Clinic Data	Form and Instruction	New	Co-occuring Disorders
198108	Patient Medical Record and Clinic Data	Form and Instruction	New	Clinical Measures
198107	Patient Navigator Focus Group	Form and Instruction	New	Participant Information Form
198107	Patient Navigator Focus Group	Form and Instruction	New	Consent Form
198107	Patient Navigator Focus Group	Form and Instruction	New	PN_Focus Group
198106	Patient Navigator Encounter/Target Services Log	Form and Instruction	New	Forms
198106	Patient Navigator Encounter/Target Services Log	Form and Instruction	New	Target Services Log
198105	Patient Navigator Survey	Form and Instruction	New	Patient Navigator Survey
198104	VR-12 Health Status Form	Form and Instruction	New	VR_English_Self
198103	Navigated Patient Data Intake Form	Form and Instruction	New	Intake and Target

ICR Details

OMB Control No: 0915-0346	ICR Reference No: 201106-0915-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program
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: Improperly submitted	Conclusion Date: 12/12/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/15/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Ten grants have been awarded to eligible entities for the development and operation of demonstration programs to provide patient navigator services to improve health care outcomes. The Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program assesses whether local initiatives can reduce the burden of cancer and other chronic diseases such as obesity, diabetes, asthma and others by reducing the barriers related to accessing high quality health care services. This evaluation consists of two parts of data collection: 1) collection of qualitative information from staff associated with the Patient Navigation Demonstration Program; and 2) quantitative data related to the demographics and care of all patientss entering PNDP, as well as patient navigators.

---

Authorizing Statute(s): PL: Pub.L. 109 - 18 0812 Name of Law: Patient Navigator Outreach and Chronic Disease Prevention Act of 2005
   US Code: 42 USC 256A Name of Law: The Public Health Service Act
   PL: Pub.L. 111 - 148 3510 Name of Law: Patient Protection and Affordable Care Act of 2010
  

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:
	76 FR 10373	02/24/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 27067	05/10/2011
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
Annual Clinic-Wide Clinical Performance Measures Report	9	Clinic-Wide Measures
Grantee Health Care Provider Focus Group	12, 14, 15	Focus_Group_Health_Provider ,   Consent Form ,   Participant Information Form
Navigated Patient Data Intake Form	1	Intake and Target
Patient Medical Record and Clinic Data	8, 7	Clinical Measures ,   Co-occuring Disorders
Patient Navigator Cultural Competency Checklist	10	Cultural Competency
Patient Navigator Encounter/Target Services Log	4, 5	Target Services Log ,   Forms
Patient Navigator Focus Group	6, 14, 15	PN_Focus Group ,   Consent Form ,   Participant Information Form
Patient Navigator Survey	3	Patient Navigator Survey
Patient Navigator/Health System Administrator Focus Group	11, 14, 15	PN_Health_Administrator_Focus_Group ,   Consent Form ,   Participant Information Form
Quarterly Report	14	Quarterly_Report
Social Service Provider Focus Group	13, 14, 15	Focus_Group_Social_Service ,   Consent Form ,   Participant Information Form
VR-12 Health Status Form	2	VR_English_Self

---

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.

---

Annual Cost to Federal Government: $455,620

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]? Yes

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

---

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: 06/15/2011

---