National Healthy Start Evaluation and Quality Assurance

Forms and Documents

Document Name	Status
Form B3 Redesigned Preconception, Pregnancy and Parenting (3P's) Information Forms 3-6 Form and Instruction	Removed
Form B2 Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Pregnancy Form and Instruction	Removed
Form 3 Parent/Child Form Form and Instruction	Modified
Form 2 Prenatal Form Form and Instruction	Modified
Form 1 Background Information Form Form and Instruction	Modified
SSupporting Statement _0915-0338_Jan 2020 Revised Clean.docx Supporting Statement A	2020-02-04
RevisedHSToolsCrosswalkOct 2 2019.xlsx Supplementary Document	2019-10-31
HealthyStartReauthorization.pdf Supplementary Document	2019-10-31

IC Document Collections

IC ID	Document Title	Status
223581	Redesigned Preconception, Pregnancy and Parenting (3P's) Information Forms 3-6 Form and Instruction	Removed
223580	Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Pregnancy Form and Instruction	Removed
211291	Healthy Start Focus Group Protocol Instruction	Removed
211290	Healthy Start Site Visit Protocol Instruction	Removed
211289	Parent/Child Form Form and Instruction	Modified
211288	Prenatal Form Form and Instruction	Modified
195559	Background Information Form Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0338	ICR Reference No: 201910-0915-005
Status: Active	Previous ICR Reference No: 201609-0915-003
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: National Healthy Start Evaluation and Quality Assurance
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: 02/11/2020
	Date Received in OIRA: 11/07/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2023	36 Months From Approved	02/29/2020
Responses	116,150	0	102,207
Time Burden (Hours)	45,652	0	31,145
Cost Burden (Dollars)	0	0	0

---

Abstract: The goal of this ongoing monitoring and evaluation is to assess Healthy Start (HS) progress towards meeting its performance goals. Results from monitoring and evaluation efforts will provide actionable evidence to support the improvement, sustainability, replication, and dissemination of the program. The information collected will be used to obtain consistent information across all 100 grantees about HS, its participants, and its outcomes. Respondents include pregnant women and women of reproductive age that were served by HS and HS staff. This revision seeks to reduce the burden of data collection on grantees and program participants, as well as to focus the evaluation more clearly on progress towards meeting performance goals regarding program impact. In the process, this will ensure that collected data is meaningful for monitoring and evaluation, and that previously separate data systems can be streamlined, thus improving efficiency.

---

Authorizing Statute(s): US Code: 42 USC 254c-8 Name of Law: Public Health Service Act
   PL: Pub.L. 110 - 339 122 Name of Law: Healthy Start Reauthorization Act of 2007
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 753	01/31/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 60095	11/07/2019
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Redesigned Preconception, Pregnancy and Parenting (3P's) Information Form: Pregnancy	B2	B2 3Ps_Pregnancy History Form_revised.doc
Background Information Form	1	FINAL NewBackground_Jan 2020.docx
Prenatal Form	2	FINALNew Prenatal Jan 2020.docx
Parent/Child Form	3	FINAL New ParentChild Jan 2020.docx
Healthy Start Site Visit Protocol
Redesigned Preconception, Pregnancy and Parenting (3P's) Information Forms 3-6	B3, B4, B5, B6	B3 3Ps_Preconception Form_revised.doc ,   B4 3Ps_Prenatal Form_revised.doc ,   B5 3Ps_Postpartum Form_revised.doc ,   B6 3Ps_Interconception_Parenting Form_revised.doc
Healthy Start Focus Group Protocol

---

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	116,150	102,207	0	13,943	0	0
Annual Time Burden (Hours)	45,652	31,145	0	14,507	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: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: This revision includes a reduction in the number as well as length of the forms that grantees are required to submit. The current OMB approval includes six forms that have been consolidated into three forms to eliminate redundancy in this request: (1) Background Information Form, (2) Prenatal Form, and (3) Parent/Child Form. The increase is due to an increase in the number of respondents.

---

Annual Cost to Federal Government: $209,023

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

---

Common Form ICR:  No

---

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: 11/07/2019

---