OWH IPV Provider Network Cross-Site Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
60-day0990-IPV Federal Register, Volume 81 Issue 83 (Friday, April 29, 2016).htm	Supplementary Document	Uploaded 2016-08-26	Available
Attachment B5_System Reminder Email .docx	Supplementary Document	Uploaded 2016-08-16	Available
Attachment B3_Initial Service Provider Contact Email.docx	Supplementary Document	Uploaded 2016-08-16	Repair queued
Attachment B4_Email for Notification about System being open.docx	Supplementary Document	Uploaded 2016-08-16	Available
SS_B.docx	Supporting Statement B	Uploaded 2016-08-16	Available
SS_A OWH IPV 2016 OMB.doc	Supporting Statement A	Uploaded 2016-08-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223062	Service Provider Interview	Other-interview	New
221106	Semi-Annual Service Provider Assessment	Other-survey	New

ICR Details

OMB Control No: 0990-0454	ICR Reference No: 201604-0990-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: OWH IPV Provider Network Cross-Site Evaluation
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: 01/30/2017
	Date Received in OIRA: 08/29/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved
Responses	150	0	0
Time Burden (Hours)	100	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Many health care providers are uncertain about how to handle disclosures of abuse and violence. As part of the administration’s efforts to create a health system that better addresses the needs of victims of interpersonal violence (IPV), the Office on Women’s Health (OWH) at the U.S. Department of Health and Human Services has established (through cooperative agreement awards) the IPV Provider Network program. The program requires collaboration between health care providers and IPV service programs to evaluate systems for integrating IPV intervention into basic clinical care. Five sites were selected to develop policies and standard procedures that provide comprehensive responses to victims of violence in health care settings.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2713 Name of Law: Patient Protection and Affordable Care 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:
	81 FR 25681	04/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 57923	08/26/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Semi-Annual Service Provider Assessment
Service Provider Interview

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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	150	0	0	150	0	0
Annual Time Burden (Hours)	100	0	0	100	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: $140,871

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]? Yes

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: 08/29/2016

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