Health Profession Opportunity Grants (HPOG) program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Attachment I - 6_month survey checkin (v2).doc	Supplementary Document	Uploaded 2012-10-17	Available
HPOG Impact Supporting Statement_Part B_revised to ACF 10.2.12 AW 10.3.2012.docx	Supporting Statement B	Uploaded 2012-10-17	Available
Attachment H _Screen Shots of the PRS.docx	Supplementary Document	Uploaded 2012-06-13	Available
Attachment G_Constructs +supplemental checks_revised 10.2.12.docx	Supplementary Document	Uploaded 2012-10-17	Available
Attachment F_Impact Analysis Plan Revised 9-28-12.doc	Supplementary Document	Uploaded 2012-10-17	Available
Attachment E_Child Roster Logic Model and Research_revised 10.2.12.doc	Supplementary Document	Uploaded 2012-10-17	Available
Attachment D_Sources and Justification for Supplemental Baseline Questions_revised 10.2.12.doc	Supplementary Document	Uploaded 2012-10-17	Available
Attachment B_Informed Consent Form_revised 10-2-12.docx	Supplementary Document	Uploaded 2012-10-17	Available
Attachment A_References_revised 9-28-12.docx	Supplementary Document	Uploaded 2012-10-17	Available
HPOG Impact Supporting Statement_Part A_revised to ACF 10.2.12 AW 10.3.2012.doc	Supporting Statement A	Uploaded 2012-10-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202865	Supplemental Baseline Questions (grantees)	Other-Supplementatal Baseline Data	New
202864	Supplemental Baseline Questions (program participants and control group members)	Other-Supplemental Questions	New
198341	#1. Semi-annual HPOG Program Performance Report	Other-Word	Modified

ICR Details

OMB Control No: 0970-0394	ICR Reference No: 201206-0970-010
Status: Historical Active	Previous ICR Reference No: 201106-0970-008
Agency/Subagency: HHS/ACF	Agency Tracking No:
Title: Health Profession Opportunity Grants (HPOG) program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/19/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/25/2012
Terms of Clearance: Approved as revised by ACF.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	24 Months From Approved	09/30/2014
Responses	10,314	0	64
Time Burden (Hours)	4,559	0	1,997
Cost Burden (Dollars)	0	0	59,531

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Abstract: ACF is implementing a multi-pronged research and evaluation approach for the HPOG program to better understand and assess the activities conducted and their results. The current submission is in support of the HPOG Impact Study (HPOG-Impact). Currently, we request a revision to OMB clearance number 0970-0394 to add baseline questions to the PRS, which is currently in use by all HPOG grantees. These added questions will be administered to HPOG-Impact study participants only, including both those in the treatment group(s) and control group, at baseline (i.e., prior to random assignment and prior to intake into the programs studied for the treatment group) in conjunction with the currently approved PRS. These Supplemental Baseline Questions will complement baseline data already being collected about the universe of HPOG program participants through the PRS.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 5507 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:
	77 FR 6126	02/07/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 36276	06/18/2012
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
#1. Semi-annual HPOG Program Performance Report
Supplemental Baseline Questions (grantees)
Supplemental Baseline Questions (program participants and control group members)

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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	10,314	64	0	10,250	0	0
Annual Time Burden (Hours)	4,559	1,997	0	2,562	0	0
Annual Cost Burden (Dollars)	0	59,531	0	-59,531	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: New survey.

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Annual Cost to Federal Government: $339,430

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: 06/25/2012

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