Data Use Agreement and Supplement for 2014 Health Center Patient Survey

Forms and Documents

Document Name	Status
Form 1 Data Use Agreement and Supplement for 2014 Health Center Patient Survey Form and Instruction	New
DUA Supporting Statement A PASSBACK CLEAN 1-25-17.docx Supporting Statement A	2017-01-25

IC Document Collections

IC ID	Document Title	Status
224072	Data Use Agreement and Supplement for 2014 Health Center Patient Survey Form and Instruction	New

ICR Details

OMB Control No: 0906-0027	ICR Reference No: 201610-0906-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Data Use Agreement and Supplement for 2014 Health Center Patient Survey
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: 03/17/2017
	Date Received in OIRA: 10/24/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved
Responses	40	0	0
Time Burden (Hours)	30	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The 2014 Health Center Patient Survey (HCPS) surveyed patients who use health centers funded under Section 330 of the Public Health Service Act. Before allowing access to unrestricted HCPS data that contains sensitive grantee and patient information protected by the Privacy Act of 1974, prospective users of the data will submit a signed data use agreement (DUA) and describe (in the associated supplement to the DUA) the proposed research they intend to undertake in using the data. Likely respondents include researchers in academia, private contractors, and Primary Care Associations/Health Center grantee organizations.

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Authorizing Statute(s): US Code: 42 USC 254b, as amended, Sec 330 Name of Law: Public Health Service Act, as amended
  

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 27452	05/06/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 69834	10/07/2016
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
Data Use Agreement and Supplement for 2014 Health Center Patient Survey	1, 1	DUA ,   DUA Supplement

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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	40	0	0	40	0	0
Annual Time Burden (Hours)	30	0	0	30	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 a new ICR, so there is an increase from zero (0).

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Annual Cost to Federal Government: $2,245

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

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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: 10/24/2016

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