WISEWOMAN National Program Evaluation: Implementation Assessment

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Discussion Guide	Form	New	Available
Discussion Guide	Form	New	Available
Awardee Partners Network Survey (Private Sector)	Form	New	Available
Clinical Provider Partners Discussion Guide	Form	New	Available
Healthy Behavior Staff Discussion Guide	Form	New	Available
Awardee Partners Site Visit	Form	New	Available
Awardee Partners Network Survey	Form	New	Available
Discussion Guide	Form	New	Available
Administrators Network Survey	Form	New	Available
Awardee Administrators Program Survey	Form	New	Available
Attachment B proposed outcomes and measures_5 27 2015.docx	Supplementary Document	Uploaded 2015-05-27	Available
Attachment B proposed outcomes and measures.docx	Supplementary Document	Uploaded 2014-12-04	Available
Attachment E5 Consent form.docx	Supplementary Document	Uploaded 2014-12-04	Available
IRB exempt.pdf	Supplementary Document	Uploaded 2014-12-04	Available
Attachment F2 Summary of Public Comments.docx	Supplementary Document	Uploaded 2014-12-04	Available
Attachment F1 Federal Register Notice.pdf	Supplementary Document	Uploaded 2014-12-04	Available
Attachment A1 A2 authorizing legislation.pdf	Supplementary Document	Uploaded 2014-12-04	Available
WISEWOMAN OMB Part B_11 07 2014.docx	Supporting Statement B	Uploaded 2014-12-04	Available
WISEWOMAN OMB Part A_5 27 2015.docx	Supporting Statement A	Uploaded 2015-05-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214159	Private Sector	Form	New	Discussion Guide
214158	(Private Sector) Awardee Partners Discussion Guide	Form	New	Discussion Guide
214157	(Private Sector) Awardee Partners Network Survey	Form	New	Awardee Partners Network Survey (Private Sector)
214155	Clinical Providers	Form	New	Clinical Provider Partners Discussion Guide
214154	Healthy Behavior Support Staff Site Visit Discussion Guide	Form	New	Healthy Behavior Staff Discussion Guide
214153	Awardee Partners Site Visit Discussion Guide	Form	New	Awardee Partners Site Visit
214152	Awardee Partners Network Survey	Form	New	Awardee Partners Network Survey
214151	Awardee Administrators Site Visit Discussion Guide	Form	New	Discussion Guide
214150	Awardee Administrators Network Survey	Form	New	Administrators Network Survey
214149	Awardee Administrators Program Survey	Form	New	Awardee Administrators Program Survey

ICR Details

OMB Control No: 0920-1068	ICR Reference No: 201412-0920-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 414AUI
Title: WISEWOMAN National Program Evaluation: Implementation Assessment
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 with change	Conclusion Date: 05/29/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/22/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved
Responses	219	0	0
Time Burden (Hours)	132	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Approval is requested for 3 years to conduct a program implementation assessment of the WISEWOMAN program (Well-Integrated Screening and Evaluation for Women Across the Nation). The proposed new information collection will gather process data to improve understanding of how WISEWOMAN awardees implement program activities. The information collection includes a program survey, a network survey, and site visits.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
   PL: Pub.L. 101 - 354 300k Name of Law: Breast and Cervical Cancer Mortality Prevention Act of 1990
  

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:
	79 FR 50653	08/25/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 74097	12/15/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
(Private Sector) Awardee Partners Discussion Guide	none	Discussion Guide
(Private Sector) Awardee Partners Network Survey	none	Awardee Partners Network Survey (Private Sector)
Awardee Administrators Network Survey	none	Administrators Network Survey
Awardee Administrators Program Survey	none	Awardee Administrators Program Survey
Awardee Administrators Site Visit Discussion Guide	none	Discussion Guide
Awardee Partners Network Survey	none	Awardee Partners Network Survey
Awardee Partners Site Visit Discussion Guide	none	Awardee Partners Site Visit
Clinical Providers	none	Clinical Provider Partners Discussion Guide
Healthy Behavior Support Staff Site Visit Discussion Guide	none	Healthy Behavior Staff Discussion Guide
Private Sector	none	Discussion Guide

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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	219	0	0	219	0	0
Annual Time Burden (Hours)	132	0	0	132	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 request.

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Annual Cost to Federal Government: $150,000

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: 12/22/2014

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