Examining how Local Health Departments Leverage Age-Friendly Cities Initiatives to Build Resilience in Elderly Populations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Survey for Older Adults - Participants	Form and Instruction	New	Available
Survey for Older Adults - Screened Out	Form and Instruction	New	Available
AttJ-Institutional_Review_Board_Exemption_Letter.docx	Supplementary Document	Uploaded 2015-07-29	Available
2015-08027 60-day FRN Examining how.pdf	Supplementary Document	Uploaded 2015-07-29	Available
AttA-Authorizing_Legislation.docx	Supplementary Document	Uploaded 2015-07-29	Available
Supporting_Statement_Part B 20160104.docx	Supporting Statement B	Uploaded 2016-01-06	Available
Supporting_Statement_Part_A 12-15-2015.docx	Supporting Statement A	Uploaded 2016-01-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217682	Interview Guide for Local HD Representative	Instruction	New
217681	Interview Guide for Senior Village Director	Instruction	New
217680	Interview Guide for Age Friendly Initiative Staff	Instruction	New
217679	Survey for Older Adults - Participants	Form and Instruction	New
217678	Survey for Older Adults - Screened Out	Form and Instruction	New

ICR Details

OMB Control No: 0920-1093	ICR Reference No: 201507-0920-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15UJ
Title: Examining how Local Health Departments Leverage Age-Friendly Cities Initiatives to Build Resilience in Elderly Populations
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: 01/06/2016
	Date Received in OIRA: 07/31/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	24 Months From Approved
Responses	1,530	0	0
Time Burden (Hours)	302	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of the study is to quantify the contribution that Age Friendly Initiatives (AFI) and Senior Villages (SV) have made to improving resilience outcome for older adults. The data will be used to provide guidance to local health departments for improving their engagement with AFIs and SVs.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

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 18846	04/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 44966	07/28/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Survey for Older Adults - Participants	none	Senior Village Survey
Survey for Older Adults - Screened Out	none	Senior Village Survey
Interview Guide for Age Friendly Initiative Staff
Interview Guide for Senior Village Director
Interview Guide for Local HD Representative

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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	1,530	0	0	1,530	0	0
Annual Time Burden (Hours)	302	0	0	302	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 ICR.

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Annual Cost to Federal Government: $307,760

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: 07/31/2015

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