Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

Forms and Documents

Document Name	Status
Form 1E Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction	New
Form 3 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form	New
Template for Generic Pretesting Package Supporting Statement A.docx Supplementary Document	2017-06-06
Supporting Statement B.docx Supporting Statement B	2017-04-04
FINALSupporting Statement A Revised 6-2-17.docx Supporting Statement A	2017-06-02

IC Document Collections

IC ID	Document Title	Status
236661	Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction	New
232178	Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form	New

ICR Details

OMB Control No: 0915-0379	ICR Reference No: 201704-0915-001
Status: Historical Active	Previous ICR Reference No: 201402-0915-003
Agency/Subagency: HHS/HSA	Agency Tracking No: 21433
Title: Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)
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 with change	Conclusion Date: 06/08/2017
	Date Received in OIRA: 04/26/2017
Terms of Clearance: Previous terms continue: Under this generic clearance, HRSA may conduct cognitive interviews, focus groups, field tests/pilot interviews, and experimental research in laboratory and field settings, both for evaluating questionnaires and more basic research on response errors in surveys. OMB will respond with approval or comments within two weeks of receipt. OMB and HRSA will revisit the terms of this generic clearance, as appropriate.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	5,225	0	15,000
Time Burden (Hours)	3,200	0	13,333
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of collections under this generic clearance is to obtain formative information from respondents to develop new questions, questionnaires and tools and to identify problems in instruments currently in use. This clearance request is limited to formative research activities emphasizing data collection, toolkit development, and estimation procedures and reports for internal decision-making and development purposes and does not extend to the collection of data for public release or policy formation. It is anticipated that these studies will rely heavily on qualitative techniques to meet their objective.

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Authorizing Statute(s): US Code: 42 USC 299c-3(c) Sec. 934(c) 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:
	82 FR 11230	02/12/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 19070	04/25/2017
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Pre-testing for 2019 Health Center Patient Survey (HCPS)	2V, 1S, 2S, 2T, 3E, 3S, 3V, 2C, 1E, 2E, 3C, 3T	Attachment 1E Patient Screening (English).docx ,   Attachment 1S Patient Screening (Spanish).docx ,   Attachment 2E Patient Screening Short Blessed Scale (English).docx ,   Attachment 2S Patient Screening Short Blessed Scale (Spanish).DOC ,   Attachment 2V Patient Screening Short Blessed Scale (Vietnamese).DOCX ,   Attachment 2C Patient Screening Short Blessed Scale (Chinese).DOCX ,   Attachment 2T Patient Screening Short Blessed Scale (Tagalog).DOCX ,   Attachment 3E Patient Survey (English) 06.21.19.docx ,   Attachment 3S Patient Survey (Spanish) 06.21.19.docx ,   Attachment 3V Patient Survey (Vietnamese) 06.21.19.docx ,   Attachment 3C Patient Survey (Chinese) 06.21.19.docx ,   Attachment 3T Patient Survey (Tagalog) 06.21.19.docx
Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument	1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 9	2018 MCH Survey Juris Module_CNMI_English_Formatted.doc ,   2018 MCH Survey Juris Module_FSM_English_Formatted.doc ,   2018 MCH Survey Juris Module_Guam_English_Formatted.doc ,   2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc ,   2018 MCH Survey Juris Module_Palau_English_Formatted.doc ,   2018 MCH Survey Juris Module_PR_English_Formatted.doc ,   2018 MCH Survey Juris Module_USVI_English_Formatted.doc ,   2018 MCH Survey Core_AS_Samoan_Formatted.doc ,   2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc ,   2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc ,   2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc ,   2018 MCH Survey Core_Palau_Palauan_Formatted.doc ,   2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx ,   2018 MCH Survey Core_Palau_Tagalog_Formatted.doc ,   2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx ,   2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc ,   2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx ,   2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx ,   2018 MCH Survey Core_English_Formatted FINAL.docx ,   2018 MCH Survey Juris Module_AS_English_Formatted.doc

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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	5,225	15,000	0	-9,775	0	0
Annual Time Burden (Hours)	3,200	13,333	0	-10,133	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Program adjusted their burden estimates to reflect current projects. Please use version 4 of SSA, thank you!

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Annual Cost to Federal Government: $2,257,000

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

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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: 04/26/2017

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