Surgeon General’s Pledge to Stem the Opioid Epidemic

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
SSA_OSG_Opioid_Pledge_Final 2.docx	Supporting Statement A	Uploaded 2016-06-07	Available
Emergency Request Memo.SG Opioid Web Site.pdf	Supplementary Document	Uploaded 2016-06-07	Available
SSB_OSG_Opioid_Pledge_Final.docx	Supporting Statement B	Uploaded 2016-06-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219848	Prescribers	Other-survey	New

ICR Details

OMB Control No: 0990-0448	ICR Reference No: 201601-0990-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Surgeon General’s Pledge to Stem the Opioid Epidemic
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 06/07/2016
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/08/2016
	Date Received in OIRA: 06/07/2016
Terms of Clearance: If this collection is anticipated to extend beyond 6 months, the Agency will proceed with formal submission of this ICR to OMB for standard review.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	6 Months From Approved
Responses	10,000	0	0
Time Burden (Hours)	667	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This information request involves collecting information from users for this pledge which recruits doctors, dentists, nurses, and physician assistants to utilize their unique position in the community and in their practice to take notice of the opioid crisis and commit to taking action that could save lives.

Emergency Justfication: I have determined that this information must be collected prior to the expiration of time periods established under Part 1320, and that this information is essential to the U.S. Surgeon General’s mission to communicate the best available public health information to the American people. The goal of this ICR is to significantly diminish the amount of opioid misuse, abuse, addiction and overdose. Nearly two million people in the U.S. have a prescription opioid use disorder, and the number of opioid overdose death have quadrupled since 1999. The epidemic is contributing to increased heroin use and the spread of HIV and hepatitis C among IV drug users.

---

Authorizing Statute(s): US Code: 42 USC 300c Name of Law: General authority of Secretary
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 5129	02/01/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Prescribers

---

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	10,000	0	0	10,000	0	0
Annual Time Burden (Hours)	667	0	0	667	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

---

Annual Cost to Federal Government: $10,000

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

---

Common Form ICR:  No

---

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: 06/07/2016

---