Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Annual Progress Report	Form	Modified	Available
Attachment 8 Consent Guidance.pdf	Supplementary Document	Uploaded 2016-11-02	Available
Attachment 7 Map of WISEWOMAN Awardees.pdf	Supplementary Document	Uploaded 2016-11-02	Available
Attachment 6 WISEWOMAN Program Managers Directors and Data Managers.pdf	Supplementary Document	Uploaded 2016-11-02	Available
Attachment 2b 0920-0612 60-day FRN 07 26 2016.pdf	Supplementary Document	Uploaded 2016-11-02	Available
Attachment 2a 0920-0612 OMB Change Request Notice Of Action.pdf	Supplementary Document	Uploaded 2016-11-02	Available
Attachment 1b Section 301 of the PH Service Act.pdf	Supplementary Document	Uploaded 2016-11-02	Available
Attachment 1a NBCCEDP Law Statute.pdf	Supplementary Document	Uploaded 2016-11-02	Available
Supporting Statement-Part_B 0920-0612.docx	Supporting Statement B	Uploaded 2016-11-02	Available
Service_Delivery_Supporting_Statement-Part_A 0920-0612 (Revised 10 31) (Clean Copy).docx	Supporting Statement A	Uploaded 2016-11-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37802	Screening and Assessment MDE and Lifestyle Program MDE	Instruction	Modified
191867	Annual Progress Report	Form	Modified

ICR Details

OMB Control No: 0920-0612	ICR Reference No: 201611-0920-003
Status: Historical Active	Previous ICR Reference No: 201608-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System
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: 12/21/2016
	Date Received in OIRA: 11/08/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	24 Months From Approved	12/31/2016
Responses	63	0	63
Time Burden (Hours)	1,344	0	1,344
Cost Burden (Dollars)	0	0	0

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Abstract: The WISEWOMAN program was established to examine ways to improve the delivery of services for women who have limited access to health care and elevated risk factors for cardiovascular disease. There are 21 awardees; two additional years are requested.

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Authorizing Statute(s): PL: Pub.L. 101 - 354 300 Name of Law: The Breast and Cervical Cancer Mortality Prevention Act of 1990
   US Code: 42 USC 241 Name of Law: Public Health Service Act
  

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 48806	07/26/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 78158	11/07/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Screening and Assessment MDE and Lifestyle Program MDE	none	WISEWOMAN data management system portal
Annual Progress Report	none	Annual Progress Report

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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	63	63	0	0	0	0
Annual Time Burden (Hours)	1,344	1,344	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: $370,250

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? Yes

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: 11/08/2016

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