42 C.F.R. Subpart B: Sterilization of Persons in Federally Assisted Family Planning Projects

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0937-0166 Record-keeping for Sterilization Consent Form	Form	Modified	Available
0937-0166 Sterilization Consent Comments Log_HHS response 4.10.19.docx	Supplementary Document	Uploaded 2019-04-11	Available
FINAL Supporting Statement - 0937-0166 sterilization 2018.doc	Supporting Statement A	Uploaded 2018-12-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7740	Information disclosure for sterilization consent forms	Other-disclosure consent form	Unchanged
191181	Record-keeping for Sterilization Consent Form	Form	Modified

ICR Details

OMB Control No: 0937-0166	ICR Reference No: 201810-0937-003
Status: Active	Previous ICR Reference No: 201506-0937-001
Agency/Subagency: HHS/OASH	Agency Tracking No:
Title: 42 C.F.R. Subpart B: Sterilization of Persons in Federally Assisted Family Planning Projects
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: 04/18/2019
	Date Received in OIRA: 12/18/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	36 Months From Approved	04/30/2019
Responses	200,000	0	200,000
Time Burden (Hours)	125,000	0	125,000
Cost Burden (Dollars)	0	0	0

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Abstract: These regulations and informed consent procedures are associated with Federally funding sterilization services. Selected consent forms are audited during the site visits and program reviews by Federal programs to ensure compliance with the regulations and protection of individual's rights.

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Authorizing Statute(s): PL: Pub.L. 42 - 241 301 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:
	83 FR 33227	07/17/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 64848	12/18/2018
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Information disclosure for sterilization consent forms
Record-keeping for Sterilization Consent Form	0937-0166	Sterilization Consent Form

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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	200,000	200,000	0	0	0	0
Annual Time Burden (Hours)	125,000	125,000	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: $27,500

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.     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: 12/18/2018

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