Tribal Maternal, Infant, and Early Childhood Home Visiting Program Performance Reporting Form 2

Forms and Documents

Document Name	Status
Form 2 Tribal Maternal, Infant, and Early Childhood Home Visiting Performance Reporting Form Form	New
Appendix 4 - Tribal MIECHV Performance Measures Numerators and Denominators.docx Supplementary Document	2017-05-16
THV Form 2 SUPSTAT.OMB.doc Supporting Statement A	2017-05-16

IC Document Collections

IC ID	Document Title	Status
226874	Tribal Maternal, Infant, and Early Childhood Home Visiting Performance Reporting Form Form	New

ICR Details

OMB Control No: 0970-0500	ICR Reference No: 201705-0970-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/ACF	Agency Tracking No:
Title: Tribal Maternal, Infant, and Early Childhood Home Visiting Program Performance Reporting Form 2
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 without change	Conclusion Date: 08/03/2017
	Date Received in OIRA: 05/19/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved
Responses	20	0	0
Time Burden (Hours)	10,000	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Social Security Act, Title V, Section 511 (42 U.S.C. §711), as amended by the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 (Public Law (Pub.L.) 114-10) created the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and authorized the Secretary of HHS (in Section 511(h)(2)(A)) to award grants to Indian tribes (or a consortium of Indian tribes), tribal organizations, or urban Indian organizations to conduct an early childhood home visiting program, through 3 percent of the total MIECHV program appropriation (authorized in Section 511(j)) for grants to tribal entities. The implementation of the program is a collaborative endeavor between Health Resources Services Administration (HRSA) and the Administration for Children and Families (ACF). HRSA administers the State MIECHV program while ACF administers the Tribal MIECHV program. The goal of the Tribal MIECHV program is to support the development of happy, healthy, and successful American Indian and Alaska Native (AIAN) children and families through a coordinated home visiting system. Tribal MIECHV grants, to the greatest extent practicable, are to be consistent with the requirements of the MIECHV grants to states and jurisdictions (authorized in Section 511(c)), and include conducting a needs assessment and establishing quantifiable, measurable benchmarks. The proposed Tribal MIECHV Form 2 (Appendix 1) will be used by Tribal MIECHV grantees to annually report their benchmark performance measures. As stipulated in the MIECHV legislation, the Tribal MIECHV grantees, like their State counterparts, must meet the required reporting of benchmark areas. The Tribal MIECHV Form 2 will be used by Tribal MIECHV grantees to begin collecting performance data in October 2017 (pending OMB approval) and then reporting performance data in October 2018 on an annual basis thereafter. The Tribal MIECHV Form 2 is new to the MIECHV Program information system and is somewhat similar to the currently-approved Tribal MIECHV Form 3 (OMB #0915-0357 Expiration: 07/31/17). The creation of Tribal MIECHV Form 2 is due to the added level of specificity and revised performance reporting requirements for grantees to report benchmarks data.

---

Authorizing Statute(s): US Code: 44 USC 711 Name of Law: Social Security Act, Title V, Section 511
   PL: Pub.L. 114 - 10 511(h)(2)(A) Name of Law: Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015
  

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:
	82 FR 7836	01/23/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 23008	05/19/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Tribal Maternal, Infant, and Early Childhood Home Visiting Performance Reporting Form	2	Tribal MIECHV Prog Performance Reporting Form 2.docx

---

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	20	0	0	20	0	0
Annual Time Burden (Hours)	10,000	0	0	10,000	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: The Tribal MIECHV Form 2 is new to the MIECHV Program information system. The creation of Tribal MIECHV Form 2 is due to the added level of specificity and revised performance reporting requirements for grantees to report benchmarks data.

---

Annual Cost to Federal Government: $480,000

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

---

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: 05/19/2017

---