Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Contact information - Spanish	Form	New	Available
Contact Information - English	Form	New	Available
CH STRONG survey - screenshots	Form	New	Available
CH STRONG survey - Spanish	Form	New	Available
CH STRONG survey	Form	New	Available
Att. 11 - References.pdf	Supplementary Document	Uploaded 2016-07-01	Available
Att. 13 - Spanish Intro.pdf	Supplementary Document	Uploaded 2016-07-01	Available
Att. 7 - Intro Letter.pdf	Supplementary Document	Uploaded 2016-07-01	Available
Att. 16 - Spanish Letter to Mother.pdf	Supplementary Document	Uploaded 2016-07-01	Available
Att. 15 - Letter to Mother.pdf	Supplementary Document	Uploaded 2016-07-01	Available
Att. 14 - Spanish Consent.pdf	Supplementary Document	Uploaded 2016-07-01	Available
Att. 5 - Consent.pdf	Supplementary Document	Uploaded 2016-07-01	Available
CH STRONG_Supporting Statement Part A_20160609_clean.docx	Supporting Statement A	Uploaded 2016-07-01	Available
Att. 16 - Spanish Letter to Mother.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 15 - Letter to Mother.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 13 - Spanish Consent.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 12 - Spanish Intro.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 10 - References.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 9 - Reminder Phone Call Script.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 8 - Postcards.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 7 - Intro Letter.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 6 - Consent.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 5 - IRB Approval Letter.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 4 - External Reviewers.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 2 - 60-Day FRN.pdf	Supplementary Document	Uploaded 2016-02-04	Available
Att. 1 - Authorizing Legislation.pdf	Supplementary Document	Uploaded 2016-02-04	Available
CH STRONG_Supporting Statement Part B_20160609_clean.docx	Supporting Statement B	Uploaded 2016-07-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
220012	Contact information - Spanish	Form	New	Contact information - Spanish
220011	Contact information - English	Form	New	Contact Information - English
220010	Survey questionnaire	Form	New	CH STRONG survey - screenshots
220010	Survey questionnaire	Form	New	CH STRONG survey - Spanish
220010	Survey questionnaire	Form	New	CH STRONG survey

ICR Details

OMB Control No: 0920-1122	ICR Reference No: 201601-0920-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15BHD
Title: Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being
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: 07/06/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/12/2016
Terms of Clearance: Approved consistent with the understanding that incentives will be provided as follows: $5 prepaid incentive sent with the survey, and a $10 incentive contingent upon completion of the survey.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	12 Months From Approved
Responses	7,565	0	0
Time Burden (Hours)	2,254	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this survey is to collect information on barriers to health care, quality of life, social and educational outcomes, and transition of care from childhood to adulthood among adults born with congenital heart defects.

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Authorizing Statute(s): US Code: 42 USC 241 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 195	10/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 7344	02/11/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Contact information - English	none	Contact Information - English
Contact information - Spanish	none	Contact information - Spanish
Survey questionnaire	none, none, none	CH STRONG survey ,   CH STRONG survey - Spanish ,   CH STRONG survey - screenshots

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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	7,565	0	0	7,565	0	0
Annual Time Burden (Hours)	2,254	0	0	2,254	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. Burden totals may be off due to rounding.

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Annual Cost to Federal Government: $882,000

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: 02/12/2016

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