Women's Preventive Health Services Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Women's Preventive Health Services Survey	Form	New	Available
Revised WPHSS_Supp St_Part A_09 14 17.docx	Supporting Statement A	Uploaded 2017-10-04	Available
Attachment 14. WPHSS_NORC IRB approval letter.pdf	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 13. WPHSS_Mid Year Thank You Letter.docx	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 12. WPHSS_Phone scripts for states to share contact information.docx	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 11. WPHSS_Letter from states to share contact information.docx	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 10. WPHSS_Final Letter_Bilingual.docx	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 9. WPHSS_Reminder Postcard Text_Bilingual.docx	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 4. WPHSS_Invitation Letter_Bilingual.docx	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 2. WPHSS_60dayFRN-DCPC-Miller.pdf	Supplementary Document	Uploaded 2017-02-08	Available
Attachment 1. Breast and Cervical Cancer Mortality Prevention Act.pdf	Supplementary Document	Uploaded 2017-02-08	Available
Revised WPHSS_Supp St_Part B_09 14 17.docx	Supporting Statement B	Uploaded 2017-10-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
225623	Eligibility Screener	Other-CATI script	New
225622	Women's Preventive Health Services Survey	Form	New

ICR Details

OMB Control No: 0920-1200	ICR Reference No: 201702-0920-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AWP
Title: Women's Preventive Health Services 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: 10/27/2017
	Date Received in OIRA: 03/02/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	36 Months From Approved
Responses	5,566	0	0
Time Burden (Hours)	1,243	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this study is to assess use of clinical preventive services, facilitators and barriers to use of clinical preventive services, and the ability to maintain consistent health insurance coverage among newly insured women who previously received cancer screenings through the National Breast and Cervical Cancer Early Detection Program. Results will inform how public health programs can support low-income medically underserved women to ensure they receive appropriate preventive health care services.

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Authorizing Statute(s): PL: Pub.L. 101 - 354 1501 Name of Law: Breast and Cervical Cancer Mortality Prevention 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 52868	08/10/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12356	03/02/2017
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
Women's Preventive Health Services Survey	none, none, none	WPHSS questionnaire ,   Survey screenshots - English ,   Survey screenshots - Spanish
Eligibility Screener

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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	5,566	0	0	5,566	0	0
Annual Time Burden (Hours)	1,243	0	0	1,243	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.

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Annual Cost to Federal Government: $448,244

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 03/02/2017

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