CHIPRA_ Children Health Insurance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Supplemental Information for OMB Review of CHIPRA ICR.docx	Supplementary Document	Uploaded 2011-12-01	Repair queued
CHIPRA-10 State Selection_ for OMB.pdf	Supplementary Document	Uploaded 2011-12-01	Available
CHIPRA-10 Sample Design Memo_for OMB.pdf	Supplementary Document	Uploaded 2011-12-01	Available
0990-CHIP OMB Supporting Statement Part B_10_19_REV.docx	Supporting Statement B	Uploaded 2011-12-01	Available
0990-CHIP Part A_Attachment G_CHIP Work Group Members.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part A_Attachment K_Site Visit Consent Procedure.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part A_Attachment_Authorizing Legislation.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part A_Attachment J__Contractor Confidentiality Pledge.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part B_Attachment A_Evaluation Design Report.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part B_Attachment I1_Focus Group Consent Form for Parents of CHIP Enrollees.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part B_Attachment I2_Focus Group Consent Form for Parents of CHIP Disenrollees.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part B_Attachment I3_Focus Group Consent Form for Parents of Eligible but Uninsured.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part A_Attachment I4_Focus Group Consent Form for Parents of Children Covered by Employer-Sponsored Insurance.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part B_Attachment C_Pretest Report.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP Part B_Attachment D__Respondent Materials.pdf	Supplementary Document	Uploaded 2011-10-19	Available
0990-CHIP OMB Supporting Statement Part A_ver4.docx	Supporting Statement A	Uploaded 2011-12-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199536	Parents and other family members of Children (focus group)	Other-focus group guide	Modified
199535	CHIP and Medicaid Personnel	Other-discussion guide	Modified
199534	Medicaid Enrollees and Disenrolles	Other-survey	Removed
199533	CHIP/Medicaid Enrollees and Disenrollees	Other-survey	Modified

ICR Details

OMB Control No: 0990-0384	ICR Reference No: 201110-0990-006
Status: Historical Active	Previous ICR Reference No: 201109-0990-002
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: CHIPRA_ Children Health Insurance
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: 12/12/2011
	Date Received in OIRA: 10/27/2011
Terms of Clearance: Approved consistent with the understanding that the results of the study will not be generalizable to the CHIP or Medicaid Programs. The design limitations will be made clear in any publications or Reports to Congress on the findings.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved
Responses	20,040	0	0
Time Burden (Hours)	10,530	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Children's Health Insurance Program Reauthorization Act (CHIPRA) 10--State Evaluation will provide the federal government with new and detailed insights into how the Children's Health Insurance Program (CHIP) has evolved since its early years, what impacts on children's coverage and access to care have occurred, and what new issues have arisen as a result of policy changes related to CHIPRA and the Patient Protection and Affordable Care Act (PPACA) of 2010 (PL 111-148).

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1 Name of Law: Patient Protection 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 17128	03/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 59701	09/27/2011
Did the Agency receive public comments on this ICR? No

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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
CHIP and Medicaid Personnel
CHIP/Medicaid Enrollees and Disenrollees
Parents and other family members of Children (focus group)
Medicaid Enrollees and Disenrolles

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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	20,040	0	0	20,040	0	0
Annual Time Burden (Hours)	10,530	0	0	10,530	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 a new collection

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Annual Cost to Federal Government: $3,062,083

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: 10/20/2011

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