Patient Centered Care Collaboration to Improve Minority Health Project

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0990-PCCC-B statistics.docx	Supporting Statement B	Uploaded 2012-01-20	Available
0990-PCCC_Houston_Deliveryform.docx	Supplementary Document	Uploaded 2012-01-20	Available
0990-PCCC_SERVICE DELIVERY FORM.docx	Supplementary Document	Uploaded 2012-01-20	Repair queued
0990-PCCC_ConsentStep VII.docx	Supplementary Document	Uploaded 2012-01-20	Available
0990-PCCC_Consent Houston.docx	Supplementary Document	Uploaded 2012-01-20	Available
0990-PCCC_Houston_Deliveryform.docx	Supplementary Document	Uploaded 2012-01-20	Repair queued
0990-PCOR-OMB Supporting Statement-Dec8-11.docx	Supporting Statement A	Uploaded 2012-01-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
200853	Post Intervention: Diabetes or Hpertension or Hperteension and Diabetes	Other-survey	New
200852	Telephone Follow-up: Healthy Eating	Other-survey	New
200851	Telephone Follow-up; Being Active and Managing Stress	Other-survey	New
200850	First Home Visit Form: Diabetes or Hypertension or Hypertension and Diabetes	Other-survey	New
200849	Houston: Eligibility Screening Form1:Hpertension and Diabetes	Other-survey	New
200848	Pst-Intervention Questionnaire	Other-questionnaire	New
200847	Intake Questionnaire HELP	Other-questionnaire	New
200846	Screening Questionnaire	Other-survey	New

ICR Details

OMB Control No: 0990-0402	ICR Reference No: 201201-0990-005
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Patient Centered Care Collaboration to Improve Minority Health Project
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 06/28/2012
	Date Received in OIRA: 01/20/2012
Terms of Clearance: HHS withdraws this collection for additional consideration. HHS may resubmit this collection using the prior 60-day and 30-day notice citations.

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

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Abstract: This data collection is for the Office of Minority Health's Patient Centered Care Collaboration to Improve Minority Health Initiative, a project that addresses the needs of these racial and ethnic minority populations. The study will explore the effect that the dissemination of two patient centered outcomes research evidenced based practices/interventions have on patients for improving their health and well being, on the likelihood of changing their behaviors and managing their health to improve their health status.

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Authorizing Statute(s): None

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 59130	09/23/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 78012	12/15/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Screening Questionnaire
Intake Questionnaire HELP
Pst-Intervention Questionnaire
Houston: Eligibility Screening Form1:Hpertension and Diabetes
First Home Visit Form: Diabetes or Hypertension or Hypertension and Diabetes
Telephone Follow-up; Being Active and Managing Stress
Telephone Follow-up: Healthy Eating
Post Intervention: Diabetes or Hpertension or Hperteension and Diabetes

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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: New collection

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Annual Cost to Federal Government: $11,615

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

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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: 01/20/2012

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