State Minority Health Entity Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0990-State And TerritorialHealthOMHSupporting Statement Part B -- OMH Oct0615.docx	Supporting Statement B	Uploaded 2015-10-20	Available
0990- State and territorial health disparitiesSupporting Statement Part A -- OMH final.100615.docx	Supporting Statement A	Uploaded 2015-10-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217164	State and Territory Survey	Other-survey	New

ICR Details

OMB Control No: 0990-0441	ICR Reference No: 201506-0990-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: State Minority Health Entity Survey
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: 12/09/2015
	Date Received in OIRA: 10/20/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved
Responses	54	0	0
Time Burden (Hours)	81	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: To best facilitate continued partnerships, OMH needs information about the current activities, challenges, and resources within state and territorial offices of minority health. The STHD Survey, which will focus on the activities, staffing, and funding of State Minority Health Entities, is part of a larger project to catalog the extent of health disparities and the activities underway to reduce them in each state and U.S. territory. The STHD Survey supports OMH's goals of working with states and territories to improve the health of racial and ethnic minority populations and eliminate health disparities.

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Authorizing Statute(s): US Code: 2 USC 551 Name of Law: Affordable Care Act (ACA) in 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:
	80 FR 26571	05/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 61824	10/14/2015
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 and Territory Survey

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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	54	0	0	54	0	0
Annual Time Burden (Hours)	81	0	0	81	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: $456,743

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: 10/20/2015

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