Title X Substainability Assessment Tool For Grantees and Service Sites

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0990-Title X Substainability Section B Statistical Methods.doc	Supporting Statement B	Uploaded 2015-06-17	Available
0990-Supporting Statement for the Title X Sustainability Assessment Tool....docx	Supporting Statement A	Uploaded 2015-12-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217085	Sustainability Assessment Sites	Other-SURVEY	New
214727	Sustainability Assessment Grantees	Other-survey	New

ICR Details

OMB Control No: 0990-0442	ICR Reference No: 201501-0990-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Title X Substainability Assessment Tool For Grantees and Service Sites
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: 12/22/2015
	Date Received in OIRA: 06/18/2015
Terms of Clearance: This collection is approved for 3 years with the determination that OPA will not use collected data to make funding decisions, but will utilize it to assess the need for additional resources to improve the sustainability of the Title X network.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved
Responses	4,260	0	0
Time Burden (Hours)	2,812	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Office of Population Affairs within the Office of the Assistant Secretary for Health seeks to collect data from the Title X centers on efforts related to (1) assisting individuals in obtaining health insurance; (2) partnerships with primary care providers; (3) availability and use of electronic health records; (4) monitoring patient care quality; (5) factors affecting revenue sources; and (6) the way that sites conduct analyses to consider the cost of providing services.

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Authorizing Statute(s): US Code: 42 USC 300 Name of Law: Title X of the Public Health Service Act
   PL: Pub.L. 111 - 148 4207 Name of Law: Patient Protection of the Affordable Care Act
   PL: Pub.L. 91 - 572 1001 Name of Law: Title X of the Public Health Service 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:
	80 FR 3593	01/23/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 34683	06/17/2015
Did the Agency receive public comments on this ICR? No

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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
Sustainability Assessment Sites
Sustainability Assessment Grantees

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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	4,260	0	0	4,260	0	0
Annual Time Burden (Hours)	2,812	0	0	2,812	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: New collection

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Annual Cost to Federal Government: $8,000

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]? 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: 06/18/2015

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