Be the Match® Patient Services Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Patient Services Survey	Form and Instruction	Modified	Available
20170921 Initial Letter_English_2017_OMB CLEAN.docx	Supplementary Document	Uploaded 2017-11-09	Available
20170921 Followup Letter_English_2017_OMB CLEAN.final.22Sept.docx	Supplementary Document	Uploaded 2017-11-09	Available
FINAL Supporting Statement_PSCS CLEAN.docx	Supporting Statement A	Uploaded 2017-11-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213555	Patient Services Survey	Form and Instruction	Modified

ICR Details

OMB Control No: 0906-0004	ICR Reference No: 201711-0906-002
Status: Historical Active	Previous ICR Reference No: 201410-0906-001
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Be the Match® Patient Services Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/20/2017
	Date Received in OIRA: 11/13/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved	12/31/2017
Responses	420	0	420
Time Burden (Hours)	105	0	105
Cost Burden (Dollars)	0	0	0

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Abstract: Be The Match® is dedicated to helping patients, caregivers and family members get the support they need to learn about their disease and treatment options, prepare for transplant and thrive after transplant. The services provided are intended to help navigate the bone marrow or cord blood transplant (transplant) process. This information will be used to determine helpfulness of existing services for a diverse population, identify areas for improvement and develop future programs.

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Authorizing Statute(s): PL: Pub.L. 111 - 264 3 Name of Law: Stem Cell Therapeutic and Research Reauthorization Act of 2010
  

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 37103	08/08/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 52311	11/13/2017
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
Patient Services Survey	1	CLEAN Office of Patient Advocacy Survey OMB revised 12-13-17.docx

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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	420	420	0	0	0	0
Annual Time Burden (Hours)	105	105	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: $19,464

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: 11/13/2017

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