WISEWOMAN National Program Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Program Survey	Form	New	Available
IRB EXPEDITED Review WISEWOMAN APPROVAL LETTER.PDF	Supplementary Document	Uploaded 2019-10-10	Available
Attachment F Federal Registrar Notice.pdf	Supplementary Document	Uploaded 2019-10-10	Available
Attachment E Consent form.docx	Supplementary Document	Uploaded 2019-10-10	Repair queued
Attachment B Public Health Service Act.pdf	Supplementary Document	Uploaded 2019-10-10	Available
Attachment A BCC Mortality Prev Act of 1990.pdf	Supplementary Document	Uploaded 2019-10-10	Available
WISEWOMAN OMB Part B.docx	Supporting Statement B	Uploaded 2019-10-10	Available
WISEWOMAN OMB Part A.docx	Supporting Statement A	Uploaded 2019-10-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
238086	Innovation Site Visit Discussion Guide - Providers	Other-Discussion Guide	New
238085	Site Visit Discussion Guide - Providers	Other-Discussion Guide	New
238084	Innovation Site Visit Discussion Guide - Support Staff	Other-Discussion Guide	New
238083	Site Visit Discussion Guide - Support Staff	Other-Discussion Guide	New
238082	Innovation Site Visit Discussion Guide - Partners	Other-Discussion Guide	New
238081	Site Visit Discussion Guide - Partners	Other-Discussion Guide	New
238080	Innovation Site Visit Discussion Guide - Administrators	Other-Discussion Guide	New
238079	Site Visit Discussion Guide - Administrators	Other-Discussion Guide	New
238078	Program Survey	Form	New

ICR Details

OMB Control No: 0920-1279	ICR Reference No: 201910-0920-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-19AWX
Title: WISEWOMAN National Program Evaluation
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 without change	Conclusion Date: 12/23/2019
	Date Received in OIRA: 10/22/2019
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved
Responses	80	0	0
Time Burden (Hours)	84	0	0
Cost Burden (Dollars)	4,382	0	0

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Abstract: The goal of the study is to assess the implementation of the WISEWOMAN program and measure the effect of the program on individual-, organizational-, and community-level outcomes. Results from the evaluation efforts will provide information about the annual and long-term performance of the program and help determine progress toward WISEWOMAN goals and outcomes. In addition, the study will document emerging, promising, and best practices that could be replicated and scaled up.

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Authorizing Statute(s): PL: Pub.L. 101 - 354 1501 Name of Law: Breast and Cervical Cancer Mortality Prevention Act of 1990
   US Code: 42 USC 241 Name of Law: PHSA
  

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:
	84 FR 25058	05/30/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 56458	10/22/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Innovation Site Visit Discussion Guide - Partners
Innovation Site Visit Discussion Guide - Support Staff
Innovation Site Visit Discussion Guide - Providers
Site Visit Discussion Guide - Partners
Program Survey	none	Program Survey
Site Visit Discussion Guide - Administrators
Innovation Site Visit Discussion Guide - Administrators
Site Visit Discussion Guide - Support Staff
Site Visit Discussion Guide - Providers

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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	80	0	0	80	0	0
Annual Time Burden (Hours)	84	0	0	84	0	0
Annual Cost Burden (Dollars)	4,382	0	0	4,382	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. Total burden and costs have been rounded up.

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Annual Cost to Federal Government: $162,671

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.     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: 10/22/2019

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