Fetal-Infant Mortality Review: Human Immunodeficiency Virus Prevention Methodology (FHPM)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2 FIMR/HIV Maternal Interview Form	Form and Instruction	New	Available
0920-09XX_Stats_SectB_FIMR-HIV_Final.doc	Supporting Statement B	Uploaded 2011-09-13	Available
Attachment 4.b Maternal Interview Consent Form - French.doc	Supplementary Document	Uploaded 2011-07-01	Available
Attachment 4.c Maternal Interview Consent Form - Creole.doc	Supplementary Document	Uploaded 2011-07-01	Available
Attachment 4.d Maternal Interview Consent Form - Spanish.doc	Supplementary Document	Uploaded 2011-07-01	Available
Attachment 3.b Maternal Interview Form - French.pdf	Supplementary Document	Uploaded 2011-07-01	Available
Attachment 3.d Maternal Interview Form - Spanish.pdf	Supplementary Document	Uploaded 2011-07-01	Available
Attachment 3.c Maternal Interview Form - Creole.pdf	Supplementary Document	Uploaded 2011-07-01	Repair queued
Maternal Interview Consent Form - Spanish.doc	Supplementary Document	Uploaded 2011-07-01	Available
Maternal Interview Consent Form - French.doc	Supplementary Document	Uploaded 2011-07-01	Available
Supporting Statement A.doc	Supporting Statement A	Uploaded 2011-09-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198412	FIMR/HIV Maternal Interview Form	Form and Instruction	New

ICR Details

OMB Control No: 0920-0902	ICR Reference No: 201107-0920-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Fetal-Infant Mortality Review: Human Immunodeficiency Virus Prevention Methodology (FHPM)
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 with change	Conclusion Date: 09/29/2011
	Date Received in OIRA: 07/06/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved
Responses	300	0	0
Time Burden (Hours)	450	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Fetal-Infant Mortality Review-Human Immunodeficiency Virus Prevention Methodology (FHPM) project is based upon the Fetal & Infant Mortality Review (FIMR). FIMR is an action-oriented community process that continually assesses, monitors, and works to improve service systems and community resources for women, infants, and families. The goal of the FIMR/HIV Prevention Methodology is to improve perinatal HIV prevention systems by using the FIMR case review and community action process. The original FIMR methodology was an approach designed to lead to community-level improvements in infant health outcomes. FHPM has adapted these steps in order to evaluate and address the causes of perinatal HIV transmission in communities. Both the FHPM and FIMR methodologies consist of four steps: Data gathering, case review, community action, and changes in community systems. The recommendations and findings of the CRT are then passed on to a Community Action Team (CAT), which is a diverse, broad-based group of community leaders and representatives capable of defining and initiating changes in the local systems. FHPM is designed to identify and address missed prevention opportunities at the community level.

---

Authorizing Statute(s): US Code: 42 USC 301 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:
	76 FR 1433	01/10/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 38654	07/01/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
FIMR/HIV Maternal Interview Form	2, 1	Maternal Interview Consent Form ,   Maternal Interview Form

---

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	300	0	0	300	0	0
Annual Time Burden (Hours)	450	0	0	450	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 ICR.

---

Annual Cost to Federal Government: $289,964

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]? 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

---

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: 07/06/2011

---