Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 HVBAT_FINAL_Revised 03.05.2020.xlsx	Form and Instruction	Modified	Available
60-day FRN MCHB HV BAT 0025.pdf	Supplementary Document	Uploaded 2020-01-09	Available
Supporting Statement Part B HVBAT 12.20.2019.docx	Supporting Statement B	Uploaded 2020-01-09	Available
Supporting Statement Part A HV BAT 12.20.2019_Revised 03.05.2020.docx	Supporting Statement A	Uploaded 2020-03-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223574	Home Visiting Budget Assistance Tool	Form and Instruction	Modified	HVBAT_FINAL_Revised 03.05.2020.xlsx

ICR Details

OMB Control No: 0906-0025	ICR Reference No: 202001-0906-001
Status: Historical Active	Previous ICR Reference No: 201609-0906-002
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies
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: 03/05/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/22/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved	03/31/2020
Responses	247	0	90
Time Burden (Hours)	4,446	0	1,440
Cost Burden (Dollars)	0	0	0

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Abstract: Original clearance under this OMB control number was for the purpose of pilot testing the reliability of a standardized cost reporting tool among evidence-based home visiting programs. HRSA has revised the data collection tool to reflect findings and recommendations from the pilot study to ensure ease of use among LIAs.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 0 Name of Law: Patient Protection and Affordable Care Act
   US Code: 42 USC 711(c), Section 511(c) of SSA Name of Law: Social Security Act Title V
  

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 37655	08/01/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 3057	01/17/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Home Visiting Budget Assistance Tool	1	HVBAT_FINAL_Revised 03.05.2020.xlsx

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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	247	90	0	157	0	0
Annual Time Burden (Hours)	4,446	1,440	0	3,006	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 increase in burden per response is based on the feedback received from grantees.

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Annual Cost to Federal Government: $87,718

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]? Yes

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: 01/22/2020

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