Wellness Program Study

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Response to OMB comments.docx	Supplementary Document	Uploaded 2011-12-22	Available
0990-WellnessProgram_PartB.doc	Supporting Statement B	Uploaded 2011-10-05	Available
Wellness Supporting Statement 122011 clean.docx	Supporting Statement A	Uploaded 2011-12-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198934	Human Resource Manager (Key Informant Interview)	Other-survey	New
198933	Employees in All Occupations	Other-survey	New
198932	Human Resource Manager	Other-survey	New

ICR Details

OMB Control No: 0990-0387	ICR Reference No: 201108-0990-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Wellness Program Study
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: 01/12/2012
	Date Received in OIRA: 08/19/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved
Responses	3,068	0	0
Time Burden (Hours)	1,587	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This data collection will be used to describe the existing use of wellness programs, including any related incentives provided to employees; examine the effectiveness of premium-based and cost-sharing incentives and other types of rewards on program participation and health behavior; and assess the impact of wellness programs on affordability of coverage and access to care, health behavior, and health outcomes.

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Authorizing Statute(s): US Code: 42 USC 1201 Name of Law: Patient Protection and Affordable Care 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:
	76 FR 17130	03/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 40913	07/12/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Employees in All Occupations
Human Resource Manager
Human Resource Manager (Key Informant Interview)

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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	3,068	0	0	3,068	0	0
Annual Time Burden (Hours)	1,587	0	0	1,587	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: $278,367

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

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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: 08/19/2011

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