Data Collection Forms for the Maternal, Infant and Early Childhood Home Visiting Program Information System

Forms and Documents

Document	Type	Status	Availability
Form 1 Home Visiting Program Information System	Form and Instruction	New	Available
B - Benchmark Areas and Constructs.docx	Supplementary Document	Uploaded 2012-08-14	Available
H - Participant list - State Panel for Review of Data Reporting Forms.docx	Supplementary Document	Uploaded 2012-08-14	Available
G - Participant list HHS-Model developer Forum.docx	Supplementary Document	Uploaded 2012-08-14	Available
F - HV Form 2 - Public Comments final 6.19.2012.pdf	Supplementary Document	Uploaded 2012-08-14	Available
E - HV Form 1 - Public Comments - Consolidated tables A TO G final 6.19.2012.pdf	Supplementary Document	Uploaded 2012-08-14	Available
A - SSA Title V Section 511.docx	Supplementary Document	Uploaded 2012-08-14	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2012-08-14	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
203751	Home Visiting Program Information System	Form and Instruction	New

ICR Details

OMB Control No: 0915-0357	ICR Reference No: 201208-0915-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Data Collection Forms for the Maternal, Infant and Early Childhood Home Visiting Program Information System
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: 10/12/2012
	Date Received in OIRA: 08/17/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	36 Months From Approved
Responses	81	0	0
Time Burden (Hours)	76,739	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Social Security Act, Title V, Section 511 (42 U.S.C. 701), as amended by the Patient Protection and Affordable Care Act of 2010, requires that MIECHV grantees collect data to measure improvements for eligible families in six specified areas (referred to as "benchmark areas") that encompass the major goals for the program. These include: 1. Improved maternal and newborn health 2. Prevention of child injuries, child abuse, neglect, or maltreatment, and reduction in emergency department visits 3. Improvement in school readiness and achievement 4. Reduction in crime or domestic violence 5. Improvement in family economic self-sufficiency 6. Improvement in the coordination and referrals for other community resources and supports

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Authorizing Statute(s): PL: Pub.L. 111 - 148 7101 Name of Law: Patient Protection and Affordable Care Act of 2010
  

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 9257	02/16/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47854	08/10/2012
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Home Visiting Program Information System	1, 2	HV Form 1 ,   HV form 2

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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	81	0	0	81	0	0
Annual Time Burden (Hours)	76,739	0	0	76,739	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 information collection.

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Annual Cost to Federal Government: $615,000

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]? 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: 08/17/2012

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