Change Memo - Spanish Translation CLEAN 9-20-2021 v2

Change Memo - Spanish Translation CLEAN 9-20-2021 v2.docx

Countermeasures Injury Compensation Program (CICP)

Change Memo - Spanish Translation CLEAN 9-20-2021 v2

OMB: 0915-0334

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Health Resources and Services

DEPARTMENT OF HEALTH & HUMAN SERVICES Administration

Shape1

Healthcare Systems Bureau

Rockville, MD 20857



DATE: October 6, 2021

TO: Josh Brammer, OMB Desk Officer

FROM: Samantha Miller, Acting HRSA Information Collection Clearance Officer

______________________________________________________________________________

Request: The Health Resources and Services Administration (HRSA), Health Systems Bureau (HSB) requests approval for changes to the Countermeasures Injury Compensation Program data collection documents (OMB 0915-0334, expiration date 03/31/2023).

Purpose: HRSA is requesting OMB’s approval of Spanish-translated versions for the Countermeasures Injury Compensation Program (CICP) Request for Benefits (RFB) form and instructions, and the Authorization for Use and Disclosure of Health Information (Authorization) form and instructions. The CICP awards compensation to individuals or survivors of individuals who are seriously injured or die as a direct result of the use or administration of a CICP covered countermeasure, like the COVID-19 vaccine. To apply for CICP benefits, a requester must submit an RFB form and Authorization form to the CICP. The CICP has experienced a significant increase in claims and inquiries from Spanish speakers related to the COVID-19 pandemic. To meet the needs of the U.S. population, the CICP would like to make the RFB and Authorization form and instructions available in Spanish in addition to English.

Changes: Instruments:

Table A includes the instruments that have been translated into Spanish, and the rationales. Attached are the RFB form (Attachment 1), RFB instructions (Attachment 2), Authorization form (Attachment 3), and the Authorization form instructions (Attachment 4), translated into Spanish. There is no difference between the English and Spanish documents in the data collection or content of the questions. A HRSA approved language translation contractor developed the Spanish language documents.

Time Sensitivity: The data collection changes must be completed in a timely manner. The CICP has a one-year filing deadline; therefore, the Spanish RFB and Authorization documents need to be available to the public as quickly as possible so that Spanish-speaking populations can access the RFB documents and file claims within the one-year filing deadline. HSB requests approval of these changes as soon as possible to meet public demand.

Burden: The changes included herein do not substantially change the estimated reporting burden for CICP requesters. Making these changes will facilitate access to the CICP claims process for Spanish-speaking requesters.

PROPOSED CLARIFICATIONS AND NON-SUBSTANTIVE CHANGES:

Table A


Instrument

Variable

Change implemented

Rationale

Request for Benefits form

Language

Translated into Spanish

This is the application for benefits in the CICP. This document is required to file a claim. CICP requesters must submit this document within one year of the date that they used or were administered a CICP-covered countermeasure. The CICP expects to have a significant increase in claims resulting from the Federal Government’s response to COVID-19.

Request for Benefits Instructions

Language

Translated into Spanish

This document is instructions on how to complete the RFB forms, and it explains possible supplemental documentation that requesters may need to provide to the CICP.

Authorization for Use or Disclosure of Health Information Form

Language

Translated into Spanish

This document is completed by the CICP requesters and provided to the CICP and the medical professionals treating the CICP requester. It provides authorization for the medical professional or facility to send the CICP the requester’s medical records.

Authorization for Use or Disclosure of Health Information Instructions

Language

Translated into Spanish

This document is the instructions for completing the Authorization for Use or Disclosure of Health Information Form.



Attachments:

  1. Request for Benefits Form (Spanish and English version)

  2. Request for Benefits Instructions (Spanish and English version)

  3. Authorization for Use or Disclosure of Health Information Form (Spanish and English versions)

  4. Authorization for Use or Disclosure of Health Information Instruction (Spanish and English versions)



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Titlechange memo
AuthorWindows User
File Modified0000-00-00
File Created2021-10-07

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