HIV Quality Measures Performance Measure Module (HIVQM Module)

Forms and Documents

Document Name	Status
Form B HIV Quality Measures Performance Measure Module (HIVQM Module) Form	New
C- 60 Day FR Notice 11_25_15.pdf Supplementary Document	2016-06-23
A - 2009 RWHAP Legislation.pdf Supplementary Document	2016-06-23
FINALHIVQM Supporting Statement A PASSBACK.docx Supporting Statement A	2016-12-08

IC Document Collections

IC ID	Document Title	Status
222138	HIV Quality Measures Performance Measure Module (HIVQM Module) Form	New

ICR Details

OMB Control No: 0906-0022	ICR Reference No: 201606-0906-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: HIV Quality Measures Performance Measure Module (HIVQM Module)
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: 12/21/2016
	Date Received in OIRA: 06/24/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved
Responses	6,948	0	0
Time Burden (Hours)	6,948	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Information collected will be used to continually monitor and evaluate HIV Performance Measures for Ryan White HIV/AIDS Program recipients. The aggregate data collected will also be critical to ensuring that HRSA can continue to respond to requests from the Secretary of the DHHS, Congress and other stakeholders. Recipients entering data will be health facilities who provide HIV care services to HIV-infected patients.

---

Authorizing Statute(s): PL: Pub.L. 111 - 87 0 Name of Law: Ryan White HIV/AIDS Treatment Extension Act of 2009
  

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:
	80 FR 227	11/25/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 113	06/13/2016
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
HIV Quality Measures Performance Measure Module (HIVQM Module)	B	Draft HIVQM Manual

---

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	6,948	0	0	6,948	0	0
Annual Time Burden (Hours)	6,948	0	0	6,948	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 an increase from zero as this is a new ICR package.

---

Annual Cost to Federal Government: $139,900

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]? 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: 06/24/2016

---