National Healthy Start Evaluation and Quality Assurance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form B3 Redesigned Preconception, Pregnancy and Parenting (3P's) Information Forms 3-6	Form and Instruction	New	Available
Form B2 Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Pregnancy	Form and Instruction	New	Repair queued
Form F Community Action Network (CAN) Survey	Form and Instruction	Modified	Available
Form B1 Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Demographic Intake	Form and Instruction	Modified	Available
Form E National Healthy Start Program Survey (NHSPS)	Form and Instruction	Modified	Available
L. Healthy Start Evaluation SOW.docx	Supplementary Document	Uploaded 2016-09-16	Repair queued
C1. Healthy Start OMB Change Memo_3Ps.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-09-16	Available
C3. Original 3 P's Information Form.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-09-16	Available
C2. Reformatted 3Ps crosswalk_Final.xlsx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-09-16	Available
K. Healthy Start Evaluation IRB Package.pdf	Supplementary Document	Uploaded 2016-09-16	Available
J2. NHSPS and CAN Pilot Test Results.docx	Supplementary Document	Uploaded 2016-09-16	Available
J1. Redesigned 3Ps Pilot Test Report.docx	Supplementary Document	Uploaded 2016-09-16	Available
D. Healthy Start Benchmarks.pdf	Supplementary Document	Uploaded 2016-09-16	Available
A. Healthy Start Reauthorization Act of 2007.pdf	Supplementary Document	Uploaded 2016-09-16	Available
Supporting Statement B_0915-0338_Revision_11-2-16.docx	Supporting Statement B	Uploaded 2016-11-04	Available
FINALSupporting Statement A_0915-0338_Revision_11-2-16.docx	Supporting Statement A	Uploaded 2016-11-04	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223581	Redesigned Preconception, Pregnancy and Parenting (3P's) Information Forms 3-6	Form and Instruction	New
223580	Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Pregnancy	Form and Instruction	New
211291	Healthy Start Focus Group Protocol	Instruction	Modified
211290	Healthy Start Site Visit Protocol	Instruction	Modified
211289	Community Action Network (CAN) Survey	Form and Instruction	Modified
211288	Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Demographic Intake	Form and Instruction	Modified
195559	National Healthy Start Program Survey (NHSPS)	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0338	ICR Reference No: 201609-0915-003
Status: Historical Active	Previous ICR Reference No: 201404-0915-007
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: National Healthy Start Evaluation and Quality Assurance
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/04/2016
	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	11/30/2019	36 Months From Approved	06/30/2017
Responses	102,207	0	41,183
Time Burden (Hours)	31,145	0	20,953
Cost Burden (Dollars)	0	0	0

---

Abstract: The national Healthy Start (HS) evaluation will include an implementation evaluation, which will describe program components that affect outcomes; a health services utilization evaluation, which will examine the characteristics of women and infants who did and did not utilize the program; and an outcome evaluation, which will assess the program’s effectiveness with regard to producing expected outcomes among the target population. The information collected will be used to obtain consistent information across all 100 grantees about HS and its outcomes and in-depth information for 15 HS communities. Respondents include pregnant women and women of reproductive age that were served by HS and HS staff.

---

Authorizing Statute(s): US Code: 42 USC 254c-8 Name of Law: Public Health Service Act
   PL: Pub.L. 110 - 339 122 Name of Law: Healthy Start Reauthorization Act of 2007
  

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 41314	06/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 62911	09/13/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Redesigned Preconception, Pregnancy and Parenting (3P's) Information Forms 3-6	B3, B4, B5, B6	B3 3Ps_Preconception Form_revised.doc ,   B4 3Ps_Prenatal Form_revised.doc ,   B5 3Ps_Postpartum Form_revised.doc ,   B6 3Ps_Interconception_Parenting Form_revised.doc
Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Pregnancy	B2	B2 3Ps_Pregnancy History Form_revised.doc
National Healthy Start Program Survey (NHSPS)	E	E. NHSPS Survey_revised.docx
Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Demographic Intake	B1	3Ps_Demographic Intake Form_revised.doc
Healthy Start Focus Group Protocol
Community Action Network (CAN) Survey	F	F. CAN Survey_revised.docx
Healthy Start Site Visit Protocol

---

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	102,207	41,183	0	61,024	0	0
Annual Time Burden (Hours)	31,145	20,953	0	10,192	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: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The same individuals (40,675) complete the Demographic Intake and Pregnancy Status/History forms, and a subset of these same individuals (20,337) also complete the Preconception, Prenatal, Postpartum, and Interconception/Parenting forms for total of 61,532 respondents and responses. A revision in the 3Ps form added to the burden amount as the instrument was separated into 6 forms from the 1 form in 2013. Information technology has assisted in decreasing the burden for some instruments.

---

Annual Cost to Federal Government: $186,719

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: 09/20/2016

---