Family-to-Family Health Information Center (F2F HIC) Feedback Surveys

Forms and Documents

Document Name	Status
Form 2 Family-to-Family Health Information Center Feedback Surveys Form and Instruction	New
Form 1 Family-to-Family Health Information Centers Data Submission Form Form and Instruction	New
60-Day FRN.pdf Supplementary Document	2018-12-06
Supporting Statement B.docx Supporting Statement B	2018-12-06
Supporting Statement A.docx V2.docx Supporting Statement A	2019-03-19

IC Document Collections

IC ID	Document Title	Status
234425	Family-to-Family Health Information Center Feedback Surveys Form and Instruction	New
234424	Family-to-Family Health Information Centers Data Submission Form Form and Instruction	New

ICR Details

OMB Control No: 0906-0040	ICR Reference No: 201812-0906-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Family-to-Family Health Information Center (F2F HIC) Feedback Surveys
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: 03/21/2019
	Date Received in OIRA: 12/10/2018
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time HRSA will request approval to extend or revise the collection if it seeks to continue the information collection activity beyond the period approved under this action.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved
Responses	1,206	0	0
Time Burden (Hours)	5,423	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The surveys will provide mechanisms to capture consistent, performance data; provide data to support the HHS Secretary's priorities of engagement; and allow HRSA to determine the extent to which F2F HICs provide service. F2F HICs can also use the data to evaluate the effectiveness of their interventions and improve services. Respondents are family members of children with special health care needs and professionals who serve such families.

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Authorizing Statute(s): US Code: 42 USC 701(c) Name of Law: Social Security Act, Title V, 501(c)
   PL: Pub.L. 114 - 10 216 Name of Law: Medicare Access and CHIP Reautorization Act of 2015
   PL: Pub.L. 115 - 123 50501 Name of Law: Bipartisan Budget Act of 2018
  

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 7482	02/21/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 63182	12/07/2018
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Family-to-Family Health Information Centers Data Submission Form	1	F2F HIC DataSubmission_Form.docx
Family-to-Family Health Information Center Feedback Surveys	2	F2FHIC_FeedbackSurveysForm.docx

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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	1,206	0	0	1,206	0	0
Annual Time Burden (Hours)	5,423	0	0	5,423	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 ICR, so burden increase is from zero (0).

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Annual Cost to Federal Government: $52,578

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: 12/10/2018

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