The HRSA Community Based Outreach Reporting Module

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4 Community Based Vaccine Outreach Program Reporting Module - Booster Vaccines 09-22-2021.docx	Form and Instruction	New	Available
Form 4 Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines	Form and Instruction	New	Repair queued
Form 3 General Outreach Activities for Community Members Form	Form and Instruction	Unchanged	Available
Form 3 General Outreach Activities for Community Members Form	Form and Instruction	Unchanged	Repair queued
Form 2 Vaccine Site Data - Outreach to Community Members Form	Form and Instruction	Unchanged	Available
Form 2 Vaccine Site Data - Outreach to Community Members Form	Form and Instruction	Unchanged	Repair queued
Form 1 Community Outreach Worker Profile Form	Form and Instruction	Unchanged	Available
Form 1 Community Outreach Worker Profile Form	Form and Instruction	Unchanged	Repair queued
Supporting Statement A - CBO Program FINAL 09-22-2021.docx	Supporting Statement A	Uploaded 2021-09-29	Repair queued
Transmittal Memo to OIRA from HRSA CBO PRA Approval Request 07.09.2021 approved.pdf	Supplementary Document	Uploaded 2021-07-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249594	Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines	Form and Instruction	New	Community Based Vaccine Outreach Program Reporting Module - Booster Vaccines 09-22-2021.docx
249594	Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines	Form and Instruction	New
248292	General Outreach Activities for Community Members Form	Form and Instruction	Unchanged	General Outreach Activities for Community Members Form
248292	General Outreach Activities for Community Members Form	Form and Instruction	Unchanged
248291	Vaccine Site Data - Outreach to Community Members Form	Form and Instruction	Unchanged	Vaccine Site Data - Outreach to Community Members Form
248291	Vaccine Site Data - Outreach to Community Members Form	Form and Instruction	Unchanged
248288	Community Outreach Worker Profile Form	Form and Instruction	Unchanged	Community Outreach Worker Profile Form
248288	Community Outreach Worker Profile Form	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0906-0064	ICR Reference No: 202109-0906-002
Status: Historical Active	Previous ICR Reference No: 202107-0906-001
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: The HRSA Community Based Outreach Reporting Module
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/01/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/30/2021
Terms of Clearance: Approve on Halloween!

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2024	36 Months From Approved	01/31/2022
Responses	12,003,000	0	8,003,000
Time Burden (Hours)	1,400,801	0	934,134
Cost Burden (Dollars)	0	0	0

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Abstract: HRSA requests approval to collect program data on its Community-Based Workforce for COVID-19 Vaccine Outreach Programs (CBO Programs), which support nonprofit private or public organizations to establish, expand, and sustain a public health workforce to prevent, prepare for, and respond to COVID-19. This data is needed to comply with requirements to monitor funds distributed under the American Rescue Plan and OMB Memo 21-20.

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Authorizing Statute(s): PL: Pub.L. 117 - 2 0 Name of Law: American Rescue Plan Act of 2021
  

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:
	86 FR 45739	08/16/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 54221	09/30/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Community Outreach Worker Profile Form	1	Community Outreach Worker Profile Form
General Outreach Activities for Community Members Form	3	General Outreach Activities for Community Members Form
Vaccine Site Data - Outreach to Community Members Form	2	Vaccine Site Data - Outreach to Community Members Form
Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines	4	Community Based Vaccine Outreach Program Reporting Module - Booster Vaccines 09-22-2021.docx

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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	12,003,000	8,003,000	0	4,000,000	0	0
Annual Time Burden (Hours)	1,400,801	934,134	0	466,667	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: Burden increase due to an addition of a 4th form for Booster Vaccines.

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Annual Cost to Federal Government: $34,906

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? Yes

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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: 09/30/2021

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