Chronic Disease Self-Management Education Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 6 CDSME Sustainability Tool	Form and Instruction	New	Available
Form 5 Semi-annual Performance Report and sample template	Form and Instruction	New	Available
Form 4 Organization Site Types	Form and Instruction	New	Available
Form 2 Participant Information Survey	Form and Instruction	New	Available
Form 3 Attendance Log	Form and Instruction	New	Available
Form 1 Workshop InfoCover Sheet	Form and Instruction	New	Repair queued
Attachment I CDSME consent form.doc	Supplementary Document	Uploaded 2013-05-31	Available
CDSME Supporting_Statement 3-4-13.doc	Supporting Statement A	Uploaded 2013-03-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206270	Chronic Disease Self-Management Education Program	Form and Instruction	New	CDSME Sustainability Tool
206270	Chronic Disease Self-Management Education Program	Form and Instruction	New	Semi-annual Performance Report and sample template
206269	Chronic Disease Self-Management Education Program	Form and Instruction	New	Organization Site Types
206269	Chronic Disease Self-Management Education Program	Form and Instruction	New	Participant Information Survey
206269	Chronic Disease Self-Management Education Program	Form and Instruction	New	Attendance Log
206269	Chronic Disease Self-Management Education Program	Form and Instruction	New	Workshop InfoCover Sheet

ICR Details

OMB Control No: 0985-0036	ICR Reference No: 201303-0985-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/ACL	Agency Tracking No: 19167
Title: Chronic Disease Self-Management Education Program
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: 07/02/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved
Responses	28,122	0	0
Time Burden (Hours)	3,990	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Administration on Aging (AoA), now part of the Administration for Community Living, will use this set of data collection tools to monitor 22 grantees that were awarded cooperative agreements in response to the "PPHF 2012 Empowering Older Adults and Adults with Disabilities through Chronic Disease Self-Management Education (CDSME) Programs financed by 2012 Prevention and Public Health Funds (PPHF-2012) funding opportunity. The PPHF is accompanied by a high level of transparency, oversight, and accountability. All recipients of PPHF must follow Health and Human Services guidance related to the tracking, monitoring and reporting on the use of PPHF financing. AoA has outlined basic requirements for reporting in the CDSME Program Announcement and in the Standard Terms and Conditions of grantees' notice of awards. These notices require each grantee to prepare and submit progress reports to AoA that will enable the agency to monitor program performance. AoA will use the information to: 1) comply with reporting requirements required by the authorizing statutes, 2) collect data for performance measures used in the justification of the budget to Congress and by program, state and national decision makers, 3) effectively manage the CDSME program at the federal, state, and local levels, 4) identify program implementation issues and technical assistance needs, 5) identify best practices to serve as the basis for developing resources to help grantees learn from and replicate these practices, and 6) to provide information for reports to Congress, other government agencies, stakeholders and to the public about grantee progress. Data will be collected from State-level public health or state unit on aging government staff, local community agency staff and volunteers involved in delivering CDSME workshops, as well as individuals who participate in CDSME workshops.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Services Act
   PL: Pub.L. 109 - 365 202 Name of Law: functions of the Assistant Secretary for Aging
   PL: Pub.L. 111 - 148 4002 Name of Law: Prevention and Public Health Fund
   PL: Pub.L. 112 - 74 220 Name of Law: Reporting
   US Code: 42 USC 1701(a)(3)(A-B), (a)(4) Name of Law: Public Health Services Act
   US Code: 42 USC 1703(a)(4) Name of Law: Public Health Services 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 43092	07/23/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 17214	03/20/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Chronic Disease Self-Management Education Program	1, 3, 2, 4	Workshop InfoCover Sheet ,   Attendance Log ,   Participant Information Survey ,   Organization Site Types
Chronic Disease Self-Management Education Program	5, 6	Semi-annual Performance Report and sample template ,   CDSME Sustainability Tool

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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	28,122	0	0	28,122	0	0
Annual Time Burden (Hours)	3,990	0	0	3,990	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 data collection effort and does not build on a previous submission.

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Annual Cost to Federal Government: $97,701

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: 03/28/2013

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