Corps Community Month Event Form

Forms and Documents

Document Name	Status
Form 1 Corps Community Day Event Forms Form	Modified
Corps Community Month Instrument Screen Shot.docx Supplementary Document	2016-05-24
FINALSupporting Statement Corps Community Month Final March 2016-2.docx Supporting Statement A	2016-05-24

IC Document Collections

IC ID	Document Title	Status
206735	Corps Community Day Event Forms Form	Modified

ICR Details

OMB Control No: 0915-0362	ICR Reference No: 201605-0915-004
Status: Historical Active	Previous ICR Reference No: 201304-0915-003
Agency/Subagency: HHS/HSA	Agency Tracking No: 19281
Title: Corps Community Month Event Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/19/2016
	Date Received in OIRA: 05/26/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2019	36 Months From Approved	07/31/2016
Responses	600	0	600
Time Burden (Hours)	30	0	30
Cost Burden (Dollars)	0	0	0

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Abstract: The goals of Corps Community Month, formerly Corps Community Day encompass the following: increase awareness of the National Health Service Corps (NHSC) to potential applicants and the greater primary health community; create a sense of community and connectedness among NHSC program participants, alumni, partners and staff; and underscore the NHSC’s role in bringing primary health care services to the nation’s neediest communities. Current program participants, alumni, NHSC Ambassadors, NHSC clinical sites, primary care organizations, and professional associations plan events and report the details of their events to BHW so that they can be added to a map of events. In order to avoid duplication of effort, eliminate confusion regarding allowable event dates, avoid data entry errors, and implement a brief post-event satisfaction survey, BHW would like to implement a standard form that event planners will use to report to BHW. The fillable form will be available online.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 254 Name of Law: Affordable Care Act of 2010
  

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 56	03/23/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 100	05/24/2016
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Corps Community Day Event Forms	1, 2	Event Planning Form ,   Satisfaction Form

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ICR Summary 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	600	600	0	0	0	0
Annual Time Burden (Hours)	30	30	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: $3,232

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 05/26/2016

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