State Offices of Rural Health TA Data Collection Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 TA Request Form	Form and Instruction	Modified	Available
SORH PIMS Report.pdf	Supplementary Document	Uploaded 2013-06-25	Available
SORH TA Trend Report Example.pdf	Supplementary Document	Uploaded 2013-06-25	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2013-06-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
186810	State Offices of Rural Health TA Data Collection Form	Form and Instruction	Modified	TA Request Form

ICR Details

OMB Control No: 0915-0322	ICR Reference No: 201307-0915-004
Status: Historical Active	Previous ICR Reference No: 201006-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 19868
Title: State Offices of Rural Health TA Data Collection Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/16/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/11/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved	09/30/2013
Responses	50	0	50
Time Burden (Hours)	625	0	625
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this data collection is to provide HRSA/ORHP with standardized information on how well each SORH grantee is meeting the technical assistance needs of their States and rural communities. Consolidated data from the form provides quantitative information about technical assistance provided directly by the SORH grant program. Respondents are each of the 50 State Office of Rural Health.

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Authorizing Statute(s): US Code: 42 USC 254r Name of Law: Public Health Service Act
   US Code: 42 USC 912 Name of Law: Social Security 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:
	78 FR 22889	04/17/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 41409	07/10/2013
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
State Offices of Rural Health TA Data Collection Form	1	TA Request Form

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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	50	50	0	0	0	0
Annual Time Burden (Hours)	625	625	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,600

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)? 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: 07/11/2013

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