Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System

Forms and Documents

Document Name	Status
Form 0920-0612 Annual Progress Report Form and Instruction	Modified
OMB Change Request Summary Final_clean_1_10_2020.docx Justification for No Material/Nonsubstantive Change	2020-03-12
0612 Att 6 MDE Submission Instructions Final.pdf Supplementary Document	2019-05-10
WISEWOMAN 1701 PIA 02-13-19.pdf Supplementary Document	2019-05-10
0612 Att 8 Consent to Participate in WISEWOMAN Prg Final.pdf Supplementary Document	2019-05-10
0612 Att 3 WISEWOMAN MDE Manual Final.pdf Supplementary Document	2019-05-10
0612 Att 2d 60-Day FRN Final.pdf Supplementary Document	2019-05-10
0612 Att 2b WISEWOMAN Prg Mgrs Directors & Data Mgrs Final.pdf Supplementary Document	2019-05-10
0612 Att 2a WISEWOMAN Awardees Final.pdf Supplementary Document	2019-05-10
0612 Att 1b PHSA Final.pdf Supplementary Document	2019-05-10
0612 Att 1a NBCCEDP Law Statute Final.pdf Supplementary Document	2019-05-10
OMB Change Request Summary 04.06.18.docx Justification for No Material/Nonsubstantive Change	2018-04-11
0612 SSB Final.docx Supporting Statement B	2019-05-10
0612 SSA Final iv tsl 051019.docx Supporting Statement A	2019-05-10

IC Document Collections

IC ID	Document Title	Status
37802	Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System Other-Screenshot	Modified
191867	Annual Progress Report Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0612	ICR Reference No: 202003-0920-006
Status: Historical Active	Previous ICR Reference No: 201905-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0612-20LC
Title: Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/17/2020
	Date Received in OIRA: 03/12/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2022	08/31/2022	08/31/2022
Responses	72	0	63
Time Burden (Hours)	1,536	0	1,344
Cost Burden (Dollars)	0	0	0

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Abstract: WISEWOMAN was able to accommodate three additional programs with the current levels of funding. The number of programs went from 21 to 24 with a corresponding minor increase in the burden table. There are no changes to the Minimum data elements or response options. modify the WISEWOMAN program’s reporting system, used to both screen and monitor participants, and to evaluate and improve program efficacy. The current WISEWOMAN information collection consists of two parts, a Progress Report and Minimum Data Elements. The are no proposed changes to the approved collection. This change request is simply to report that three additional recipients were accommodated within the existing level of federal funding. Having 24 recipients instead of 21 recipients does slightly change the number of responses collected annually with a minor increase in burden.

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Authorizing Statute(s): PL: Pub.L. 101 - 354 300 Name of Law: The Breast and Cervical Cancer Mortality Prevention Act of 1990
   US Code: 42 USC 241 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 66269	12/26/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 26107	06/05/2019
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
Annual Progress Report	0920-0612	Annual Progress Report
Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System	0920-0612	WISEWOMAN Program MDE Manual Version 9.0 July 2013

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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	72	63	0	9	0	0
Annual Time Burden (Hours)	1,536	1,344	0	192	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: A minor change in burden is projected based on the increase of three additional programs.

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Annual Cost to Federal Government: $376,950

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: 03/12/2020

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