National Amyotrophic Lateral Sclerosis (ALS) Registry

Forms and Documents

Document Name	Status
ALS Biorepository Collection Form- Saliva Form	Unchanged
National Office Outreach Reporting Form	Unchanged
Outreach Reporting Form for Chapters and Districts Form	Unchanged
Annual Update for Projects Receiving Specimens or Data Form	Unchanged
ALS Registry Research Application Form	Modified
ALS Biorepository Specimen Processing Form	Unchanged
ALS DIsease Progression Survey Form	Modified
Voluntary Survey Modules Form	Unchanged
ALS Case Registration Form	Unchanged
ALS Validation Questions Form	Unchanged
0923-0041 Change Request Justification 20180905 V2.docx Justification for No Material/Nonsubstantive Change	2018-09-07
Attach_8E-National ALS Biorepository (Saliva) Consent Form 20161024.docx Supplementary Document	2016-11-08
Attachment_14- Bioorepository Pilot Study Report 20161024.pdf Supplementary Document	2016-11-08
Attach_11A-ALS Registry Research Application Form clean 20161103.docx Supplementary Document	2016-11-08
Attach_10-Privacy Impact Assessment V2.pdf Supplementary Document	2016-06-22
Attach_9B-IRB Approval to add biorepository.docx Supplementary Document	2016-06-22
Attach_9A-Current IRB Approval memo.docx Supplementary Document	2016-06-22
Attach_8D-National ALS Biorepository Consent Form Addendum (PM Skin) final.docx Supplementary Document	2016-06-22
Attach_8C-National ALS Biorepository (Postmortem) Consent Form final.docx Supplementary Document	2016-06-22
Attach_8B-National ALS Biorepository (Biospecimen) Consent Form clean 20161024.docx Supplementary Document	2016-11-08
Attach_8A-National ALS Registry Consent Form final.docx Supplementary Document	2016-06-22
Attach_7-Privacy Statement.doc Supplementary Document	2016-06-22
Attach_3-Summary of Changes to ICR.docx Supplementary Document	2016-06-22
Attach_2-60-day-FRN.pdf Supplementary Document	2016-06-22
Attach_1-Public Health Law 110-373.doc Supplementary Document	2016-06-22
SSB National ALS Registry clean 20161103.docx Supporting Statement B	2016-11-08
SSA National ALS Registry clean 20161103.docx Supporting Statement A	2016-11-08

IC Document Collections

IC ID	Document Title	Status
224351	ALS Biorepository Collection Form- Saliva Form	Unchanged
222089	National Office Outreach Reporting Form	Unchanged
222088	Outreach Reporting Form for Chapters and Districts Form	Unchanged
222087	Annual Update for Projects Receiving Specimens or Data Form	Unchanged
222085	ALS Registry Research Application Form	Modified
222083	ALS Biorepository Specimen Processing Form	Unchanged
192032	ALS DIsease Progression Survey Form	Modified
192031	Voluntary Survey Modules Form	Unchanged
192030	ALS Case Registration Form	Unchanged
192029	ALS Validation Questions Form	Unchanged

ICR Details

OMB Control No: 0923-0041	ICR Reference No: 201809-0923-001
Status: Historical Active	Previous ICR Reference No: 201606-0923-001
Agency/Subagency: HHS/TSDR	Agency Tracking No: 0923-0041-18AZK
Title: National Amyotrophic Lateral Sclerosis (ALS) Registry
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/10/2018
	Date Received in OIRA: 09/11/2018
Terms of Clearance: Prior TOC continue to apply: This collection is approved consistent with the understanding that ATSDR will not be disseminating any prevalence or incidence estimates based solely on the registration component of the Registry. Rather, registration results will be combined with administrative record results prior to dissemination of prevalence rates. Furthermore, any research based on registry data should highlight what is known about its lack of representativeness due to its self-selected nature. ATSDR endeavors to improve both the completeness and representativeness of the data over time.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	11/30/2019	11/30/2019
Responses	8,549	0	8,549
Time Burden (Hours)	1,882	0	1,882
Cost Burden (Dollars)	0	0	0

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Abstract: As mandated by Congress, the goal is to continue collecting data for the National Amyotrophic Lateral Sclerosis (ALS) Registry to better describe the incidence and prevalence of ALS and to identify risk factors for the disease. ATSDR endeavors to improve the completeness, representativeness, and accuracy of the Registry data over time. This Non-Substantive Change Request is being submitted for the addition of a question to Survey 17 about the use of a newly FDA approved drug, Radicava, for the treatment of ALS. There is no change in Burden Hours or Respondents.

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Authorizing Statute(s): PL: Pub.L. 110 - 373 2 Name of Law: Amendment to the 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:
	81 FR 21876	04/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 43202	07/01/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
ALS Biorepository Specimen Processing	none	Biorepository Specimen Processing Form
ALS Case Registration	none	ALS Case Registration
Voluntary Survey Modules	none	Voluntary ALS Survey Modules
ALS DIsease Progression Survey	none	Disease Progression Survey - survey modules
ALS Validation Questions	none	ALS Case Validation Questions
Annual Update for Projects Receiving Specimens or Data	none	Annual Update for Projects Receiving Specimens or Data
ALS Registry Research Application	none, none	Registry Research Application ,   ALS Registry Research Application
Outreach Reporting Form for Chapters and Districts	none	Outreach Reporting for Chapters and Districts
National Office Outreach Reporting	none	National Office Outreach Reporting
ALS Biorepository Collection Form- Saliva	none	Biorepository Saliva Collection Form

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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	8,549	8,549	0	0	0	0
Annual Time Burden (Hours)	1,882	1,882	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: $3,640,822

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.     Yes

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: 09/11/2018

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