Mashpee Wampanoag Indian Health Service Unit Community Health Assessment

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0917-Mashpee Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	Form and Instruction	New	Available
Part A-FINAL Mashpee submission.docx	Supporting Statement A	Uploaded 2018-06-13	Available
Part B- Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx	Supporting Statement B	Uploaded 2018-06-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231678	Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	Form and Instruction	New

ICR Details

OMB Control No: 0917-0039	ICR Reference No: 201707-0917-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Mashpee Wampanoag Indian Health Service Unit Community Health Assessment
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: 06/19/2018
	Date Received in OIRA: 08/02/2017
Terms of Clearance: This collection is approved consistent with the understanding that once IHS has a contractor on board, they will submit an amended Part B to OMB that includes the sampling plan, collection protocol, and analysis plan. The change request must be approved by OMB before beginning the study. No additional request for public comment is needed.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved
Responses	324	0	0
Time Burden (Hours)	135	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The collection of information is used to evaluate the health care needs of the Mashpee Wampanoag Tribal community. As a healthcare organization, the Mashpee Wampanoag Health Service Unit has questions regarding a respondent’s health status, behavior and social practices as well as environmental concerns. These answers will help the organization assess healthcare needs of the community and guide the implementation of programs. The Mashpee Wampanoag Tribal Health Service Unit will be able to assess the community’s needs and plan our programs accordingly to improve the health and well-being of the community.

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Authorizing Statute(s): 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:
	82 FR 11361	02/22/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 23260	05/22/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	0917-Mashpee	Mashpee Wampanoag Indian Health Service Unit Community Health Assessment

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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	324	0	0	324	0	0
Annual Time Burden (Hours)	135	0	0	135	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 IC.

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Annual Cost to Federal Government: $98,081

Does this IC contain surveys, censuses, or employ statistical methods? No

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.     No

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: 08/02/2017

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