Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Revised Pharmacy Cost Form	Form	Unchanged	Available
Revised Clinic Cost Form	Form	Unchanged	Available
Revised Staff Communication Questionnaire	Form	Unchanged	Available
Revised Key Informant Interview Script	Form	Unchanged	Available
Interviewer Data Collection Worksheet	Form	Unchanged	Available
Change Request Justification.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-10-02	Available
Project Determination 0920-1019.pdf	Supplementary Document	Uploaded 2015-05-19	Available
Att 2a_Public Comment.docx	Supplementary Document	Uploaded 2015-05-19	Available
Att 2_60-Day FRN.pdf	Supplementary Document	Uploaded 2015-05-19	Available
Supporting Statement B.docx	Supporting Statement B	Uploaded 2015-05-19	Available
Supporting Statement A_OMB comments_KB_clean copy.docx	Supporting Statement A	Uploaded 2015-08-06	Available
Att 1_Auth Legislation.pdf	Supplementary Document	Uploaded 2014-03-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216729	Pharmacy Cost Form	Form	Unchanged	Revised Pharmacy Cost Form
216728	Clinic Staff Cost Form	Form	Unchanged	Revised Clinic Cost Form
216727	Project Staff Communication Questionnaire	Form	Unchanged	Revised Staff Communication Questionnaire
216726	Key Informants Interview	Form	Unchanged	Revised Key Informant Interview Script
216726	Key Informants Interview	Form	Unchanged	Interviewer Data Collection Worksheet
210980	Pharmacy Record Abstraction Form	Other-WORD	Unchanged
210979	Quarterly Patient Information Form	Instruction	Modified
210978	Initial Patient Information Form	Instruction	Unchanged
210977	Patient Demographic Information Form	Other-WORD	Unchanged
210976	Project Pharmacy Characteristics Form	Other-WORD	Unchanged
210975	Project Clinic Characteristics Form	Other-WORD	Unchanged

ICR Details

OMB Control No: 0920-1019	ICR Reference No: 201509-0920-012
Status: Historical Active	Previous ICR Reference No: 201505-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 15BHG
Title: Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/06/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/06/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	08/31/2018	08/31/2018
Responses	10,400	0	10,400
Time Burden (Hours)	6,043	0	6,043
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Disease Control and Prevention (CDC) has started the development and implementation of a model of HIV care that integrates community pharmacists with primary medical providers for patient-centered HIV care. This revision request will help CDC determine changes to clinic and pharmacy work systems, processes and outcomes in relation to the model project and how and if the model program improves patient outcomes through improved communication and collaboration between patients' clinical providers and pharmacists.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: 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 5114	01/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 30682	05/29/2015
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
Clinic Staff Cost Form	none	Revised Clinic Cost Form
Initial Patient Information Form
Key Informants Interview	none, none	Interviewer Data Collection Worksheet ,   Revised Key Informant Interview Script
Patient Demographic Information Form
Pharmacy Cost Form	none	Revised Pharmacy Cost Form
Pharmacy Record Abstraction Form
Project Clinic Characteristics Form
Project Pharmacy Characteristics Form
Project Staff Communication Questionnaire	none	Revised Staff Communication Questionnaire
Quarterly Patient Information 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	10,400	10,400	0	0	0	0
Annual Time Burden (Hours)	6,043	6,043	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: $990,016

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: 10/06/2015

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