Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies	Form and Instruction	New	Repair queued
Attachment 6_60-day FRN.pdf	Supplementary Document	Uploaded 2016-09-15	Available
Attachment 5_Thank you Email_FINAL.doc	Supplementary Document	Uploaded 2016-09-15	Repair queued
Attachment 4_Reminder Email_FINAL.doc	Supplementary Document	Uploaded 2016-09-15	Available
Attachment 3_Invitation Email_FINAL.doc	Supplementary Document	Uploaded 2016-09-15	Available
Supporting Statement Part B FINAL.docx	Supporting Statement B	Uploaded 2016-09-15	Available
Supporting Statement Part A FINAL.docx	Supporting Statement A	Uploaded 2016-09-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223574	Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies	Form and Instruction	New

ICR Details

OMB Control No: 0906-0025	ICR Reference No: 201609-0906-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies
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: 02/28/2017
	Date Received in OIRA: 09/20/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved
Responses	90	0	0
Time Burden (Hours)	1,440	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection is requested to conduct a pilot study to test a standardized cost reporting tool among Federal Home Visiting Program local implementing agencies (LIAs). The information collected regarding national home visiting model implementation costs will be used to provide technical assistance to LIAs and model developers around cost data reporting to support continued scale-up and long-term sustainability of the program.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 0 Name of Law: Patient Protection and Affordable Care Act
   US Code: 42 USC 711(c), Section 511(c) of SSA Name of Law: Social Security Act Title V
  

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 39931	06/20/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 62511	09/09/2016
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies	2, 1	Attachment 1_Cost Tool_FINAL ,   Attachment 2_Pilot Test Questionnaire_FINAL.doc

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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	90	0	0	90	0	0
Annual Time Burden (Hours)	1,440	0	0	1,440	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 ICR, an increase from zero (0).

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Annual Cost to Federal Government: $87,718

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: 09/20/2016

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