SSA Health IT Partner Assessment - Participating Facilities and Available Content Form, SSA-680

Forms and Documents

Document Name	Status
Form SSA-680 Health IT Partner Assessment - SSA-680 Form	New
Supporting Statement.docx Supporting Statement A	2012-07-16
Addendum 0960-NEW SSA-680.doc Supporting Statement B	2012-05-22

IC Document Collections

IC ID	Document Title	Status
201618	Health IT Partner Assessment - SSA-680 Form	New

ICR Details

OMB Control No: 0960-0798	ICR Reference No: 201201-0960-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: SSA Health IT Partner Assessment - Participating Facilities and Available Content Form, SSA-680
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 without change	Conclusion Date: 10/03/2012
	Date Received in OIRA: 07/19/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	36 Months From Approved
Responses	30	0	0
Time Burden (Hours)	150	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: To support expansion of SSA's health information technology (IT) initiative as defined under the HITECH Act, SSA developed Form SSA-680. The SSA-680 allows healthcare providers to provide the information SSA needs to evaluate and determine their ability to exchange health information with us electronically. The respondents are health care and other organizations interested in entering into a health IT partnership with SSA.

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Authorizing Statute(s): US Code: 42 USC 17902 Name of Law: HITECH 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:
	77 FR 4854	01/31/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 41874	07/16/2012
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Health IT Partner Assessment - SSA-680	SSA-680	Health IT Partner Assessment

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ICR Summary 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	30	0	0	30	0	0
Annual Time Burden (Hours)	150	0	0	150	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 that will increase the public reporting burden.

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Annual Cost to Federal Government: $1

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)? Yes

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: 07/19/2012

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