Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

Forms and Documents

Document Name	Status
Form 0917-0036 Indian Health Service National Health Coaching Pilot Project Registration Form and Instruction	Unchanged
Form 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey Form and Instruction	Unchanged
Form 9017-0036 Patient Satisfaction Survey - Crownpoint Service Unit Form and Instruction	Unchanged
Form 0916-0036 OIT RPMS Training Post Class Survey Form and Instruction	Unchanged
Form 0917-0036 Laboratory Training Evaluation Form and Instruction	Unchanged
Form 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey Form and Instruction	Unchanged
Form 9017 Health Promotion Disease Prevention Activities Registration Form and Instruction	Unchanged
Form 1 WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Form and Instruction	Unchanged
Form 0917-0036 OIT RPMS Training Needs Assessment Survey Form and Instruction	Unchanged
Form 0917-0036 Patient Experience Surveys - White Earth Service Unit Form and Instruction	Unchanged
Form 0917-0036 Diabetes Care Survey Form and Instruction	Unchanged
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey Form and Instruction	Unchanged
Form 9017-0036 Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Form and Instruction	Unchanged
Form 9017-0036 Tele-Behavioral Health Center of Excellence (TBHCE) Survey Form and Instruction	Unchanged
Form 87 Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Form and Instruction	Unchanged
Form 0917-0036-86 Confer Satisfaction Survey Form	Unchanged
Form 9017-0036 IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Form and Instruction	Unchanged
Form 0917-0036 Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits Form and Instruction	Unchanged
Form 0917-0036 IHS White Earth Hand Washing Survey Form and Instruction	Unchanged
Form 0917-0036 Fort Washakie Medical Home Patient Feedback Form and Instruction	Unchanged
Form 0917-0036-12 Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service Form and Instruction	Unchanged
Form 0917-0036-23 IHS Training Needs Survey Form and Instruction	Unchanged
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Form	Unchanged
Form 0917-0036 WebTMA Survey Form and Instruction	Unchanged
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey Form	Unchanged
Form 0917-0036 Public Health Nursing Data Mart Survey Form and Instruction	Unchanged
Form 0917-0036 Patient Experience of Care Survey Pilot Project Form and Instruction	Unchanged
Form IHS Web Services C IHS Web Services Customer Satisfaction Survey Form	Unchanged
Form 0917-0036 OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. Form and Instruction	Unchanged
Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction	Unchanged
Form 0917-0036 Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit Form and Instruction	Unchanged
Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Form and Instruction	Unchanged
Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction	Unchanged
Form 0917-0036 Chinle Service Unit (CSU) Employee Satisfaction Survey. Form and Instruction	Unchanged
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction	Unchanged
Form 0917-0036 Clinical Decision Support Usability Assessment Form and Instruction	Unchanged
Form 0917-0036 User satisfaction data collection for the IHS OIT NDW Form and Instruction	Unchanged
Form 0917-0036 We Care Survey, Northern Cheyenne Form and Instruction	Unchanged
Form 0917-0036 We Care Survey, Blackfeet Community Hospital. Form and Instruction	Unchanged
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey Form and Instruction	Unchanged
Form 0917-0036 IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction	Unchanged
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction	Unchanged
Form 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction	Unchanged
Form 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey Form and Instruction	Unchanged
Form 0917-0036 Patient Flow Time Study Form and Instruction	Unchanged
Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Form and Instruction	Unchanged
Form 0917-0036 eLearning Hands-on Customer Satisfaction Survey Form and Instruction	Unchanged
Form 0917-0036 Computer Based Post Class Survey Form and Instruction	Unchanged
Form 0917-0036 IHS Patient Experience Survey Form and Instruction	Unchanged
Form 0917-0036 IHS Pharmacy Automation 2015 Survey Form and Instruction	Unchanged
Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback Form and Instruction	Unchanged
Form 0917-0036 IHS CHR NET Plenary Evaluation Form Form and Instruction	Unchanged
Form 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation Form and Instruction	Unchanged
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket Form and Instruction	Unchanged
Form 0917-0036 Physician/Dentist Customer Service Questionnaire Form and Instruction	Unchanged
Form 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS Form and Instruction	Unchanged
Form 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS Form and Instruction	Unchanged
Form 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey Form and Instruction	Unchanged
Form 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey Form and Instruction	Unchanged
Form 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey Form and Instruction	Unchanged
Form 0917-0036 Indian Health Service (IHS Website Feedback Form Form and Instruction	Unchanged
Supporting Statement A for OMB No. 0917-0036, IHS Fast Track for Generic Clearance 2022 Final 1.13.22.docx Supporting Statement A	2022-01-13
Justification for Burden Increase.docx Justification for No Material/Nonsubstantive Change	2013-01-18

IC Document Collections

IC ID	Document Title	Status
250384	Indian Health Service National Health Coaching Pilot Project Registration Form and Instruction	Unchanged
250081	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey Form and Instruction	Unchanged
250077	Patient Satisfaction Survey - Crownpoint Service Unit Form and Instruction	Unchanged
249370	OIT RPMS Training Post Class Survey Form and Instruction	Unchanged
249152	Laboratory Training Evaluation Form and Instruction	Unchanged
248810	Anticoagulation Clinic Patient Satisfaction Survey Form and Instruction	Unchanged
248668	Health Promotion Disease Prevention Activities Registration Form and Instruction	Unchanged
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Form and Instruction	Unchanged
242056	OIT RPMS Training Needs Assessment Survey Form and Instruction	Unchanged
237875	Patient Experience Surveys - White Earth Service Unit Form and Instruction	Unchanged
237873	Diabetes Care Survey Form and Instruction	Unchanged
236418	IHS Chinle Service Unit Customer Experience Survey Form and Instruction	Unchanged
236413	Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Form and Instruction	Unchanged
236408	Tele-Behavioral Health Center of Excellence (TBHCE) Survey Form and Instruction	Unchanged
235443	Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Form and Instruction	Unchanged
235441	Confer Satisfaction Survey Form	Unchanged
235243	IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Form and Instruction	Unchanged
230847	Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits Form and Instruction	Unchanged
230260	IHS White Earth Hand Washing Survey Form and Instruction	Unchanged
229103	Fort Washakie Medical Home Patient Feedback Form and Instruction	Unchanged
228427	Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service Form and Instruction	Unchanged
227895	Innovative Session Partnership Conference Other-Discussion Questions	Unchanged
227765	IHS Training Needs Survey Form and Instruction	Unchanged
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Form	Unchanged
226049	WebTMA Survey Form and Instruction	Unchanged
225049	Telebehavioral Health Patient Satisfaction Survey Form	Unchanged
225048	Public Health Nursing Data Mart Survey Form and Instruction	Unchanged
224877	Patient Experience of Care Survey Pilot Project Form and Instruction	Unchanged
223611	IHS Web Services Customer Satisfaction Survey Form	Unchanged
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. Form and Instruction	Unchanged
217933	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction	Unchanged
217932	Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit Form and Instruction	Unchanged
217748	Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Form and Instruction	Unchanged
217747	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction	Unchanged
217690	Chinle Service Unit (CSU) Employee Satisfaction Survey. Form and Instruction	Unchanged
217673	We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction	Unchanged
216572	Clinical Decision Support Usability Assessment Form and Instruction	Unchanged
216545	User satisfaction data collection for the IHS OIT NDW Form and Instruction	Unchanged
216544	We Care Survey, Northern Cheyenne Form and Instruction	Unchanged
216538	We Care Survey, Blackfeet Community Hospital. Form and Instruction	Unchanged
216532	Catawba Service Unit Patient Satisfaction Survey Form and Instruction	Unchanged
216531	IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction	Unchanged
216529	We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction	Unchanged
216514	Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction	Unchanged
216512	White Earth Dental Clinic Patient Satisfaction Survey Form and Instruction	Unchanged
216510	Patient Flow Time Study Form and Instruction	Unchanged
216509	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Form and Instruction	Unchanged
216500	eLearning Hands-on Customer Satisfaction Survey Form and Instruction	Unchanged
216499	Computer Based Post Class Survey Form and Instruction	Unchanged
216493	IHS Patient Experience Survey Form and Instruction	Unchanged
216464	IHS Pharmacy Automation 2015 Survey Form and Instruction	Unchanged
216462	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback Form and Instruction	Unchanged
216457	IHS CHR NET Plenary Evaluation Form Form and Instruction	Unchanged
216453	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation Form and Instruction	Unchanged
216429	OIT Customer Satisfaction Survey – Problem Ticket Form and Instruction	Unchanged
216426	Physician/Dentist Customer Service Questionnaire Form and Instruction	Unchanged
216424	Patient Assessment –Clinton Service Unit - IMPRESS Form and Instruction	Unchanged
216421	Employee Assessment- Clinton Service Unit - IMPRESS Form and Instruction	Unchanged
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey Form and Instruction	Unchanged
216415	Indian Health Service (IHS) FY_ eLearning Post Class Survey Form and Instruction	Unchanged
216412	Indian Health Service (IHS) FY_ Classroom Post Class Survey Form and Instruction	Unchanged
216396	Indian Health Service (IHS Website Feedback Form Form and Instruction	Unchanged

ICR Details

OMB Control No: 0917-0036	ICR Reference No: 202201-0917-001
Status: Received in OIRA	Previous ICR Reference No: 201804-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No: 1
Title: Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/13/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2022
Responses	105,000	105,000
Time Burden (Hours)	17,500	17,500
Cost Burden (Dollars)	0	0

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Abstract: This fast track generic collection of information is neccesssary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: SETTING CUSTOMER SERVICE STANDARDS
   US Code: 44 USC 3501 Name of Law: Paperwork Reduction 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:
	86 FR 54462	10/01/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 1764	01/12/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 62

IC Title	Form No.	Form Name
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
Anticoagulation Clinic Patient Satisfaction Survey	0917-0036	Anticoagulation Clinic Patient Satisfaction Survey
Catawba Service Unit Patient Satisfaction Survey	0917-0036	Catawba Service Unit Patient Satisfaction Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey.	0917-0036	CSU Employee Survey 2015
Clinical Decision Support Usability Assessment	0917-0036	Clinical Decision Support Usability Assessment
Computer Based Post Class Survey	0917-0036	Computer Based Training (CBT)Post Class Survey
Confer Satisfaction Survey	0917-0036-86	Confer Satisfaction Survey
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	9017-0036	HPV Survey
Diabetes Care Survey	0917-0036	Diabetes Care Survey
Employee Assessment- Clinton Service Unit - IMPRESS	0917-0036	Employee Assessment- Clinton Service Unit - IMPRESS
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	0917-0036	Evaluation Survey
Fort Washakie Medical Home Patient Feedback	0917-0036	Fort Washakie Medical Home Patient Feedback
Health Promotion Disease Prevention Activities Registration	9017	9017
IHS CHR NET Plenary Evaluation Form	0917-0036	IHS CHR NET Plenary Evaluation Form
IHS Chinle Service Unit Customer Experience Survey	0917-0036, 0917-0036	Community Nutrition ,   Gardening Survey
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	0917-0036, 0917-0036	Community Nutrition Gardening Survey ,   RDN Services Survey
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	9017-0036	IHS CHR Survey
IHS Patient Experience Survey	0917-0036	IHS Patient Experience Survey
IHS Pharmacy Automation 2015 Survey	0917-0036	IHS Pharmacy Automation 2015 Survey
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	0917-0036	Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
IHS Training Needs Survey	0917-0036-23	Training Needs Survey
IHS Web Services Customer Satisfaction Survey	IHS Web Services Customer Feedback	IHS Web Services Customer Feedback
IHS White Earth Hand Washing Survey	0917-0036	Hand Washing Survey
Indian Health Service (IHS Website Feedback Form	0917-0036, 0917-0036	IHS Website Feedback Form ,   IHS Website Customer Satisfaction Survey - First Page
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	0917-0036	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	0917-0036	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
Indian Health Service (IHS) FY_ Classroom Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ Classroom Post Class Survey
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	0917-0036, 0917-0036	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey ,   FY___Satellite Classroom with Areas Post Class Survey
Indian Health Service (IHS) FY_ eLearning Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ eLearning Post Class Survey
Indian Health Service National Health Coaching Pilot Project Registration	0917-0036	HCW Application
Innovative Session Partnership Conference
Laboratory Training Evaluation	0917-0036	Lab Survey
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	87, 87-1	MAT Provider Survey ,   PrEP Questionnaire
OIT Customer Satisfaction Survey – Problem Ticket	0917-0036, 0917-0036	OIT Customer Satisfaction Survey – Problem Ticket ,   OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
OIT RPMS Training Needs Assessment Survey	0917-0036	FY21 OIT RPMS Training Needs Assessment Survey
OIT RPMS Training Post Class Survey	0916-0036, 0917-0036	ELearning Survey ,   Classroom Survey
OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036	Wellness Center Survey ,   Adolescent School Health ,   Community Nutrition Survey ,   Diabetes Survey ,   Health Promotion Survey ,   Native Medicine Survey ,   Public Health Nursing - for Patient Care Giver - Survey ,   Public Health Nursing - for Patient
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
Patient Assessment –Clinton Service Unit - IMPRESS	0917-0036	Patient Assessment –Clinton Service Unit - IMPRESS
Patient Experience Surveys - White Earth Service Unit	0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036	Dental Survey ,   Lab Dept Survey ,   Optometry Survey ,   Radiology Dept Survey ,   Therapist Survey
Patient Experience of Care Survey Pilot Project	0917-0036	Patient Experience of Care Survey
Patient Flow Time Study	0917-0036	Patient Flow Time Study
Patient Satisfaction Survey - Crownpoint Service Unit	9017-0036	Patient Survey
Patient Satisfaction Survey, Alburquerque Service Unit	0917-0036	Patient Satisfaction Survey, Alburquerque Service Unit
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	0917-0036-12	Patient Satisfaction Survey for the White Earth Optometry Dept.
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	0917-0036	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
Physician/Dentist Customer Service Questionnaire	0917-0036	Physician/Dentist Customer Service Questionnaire
Public Health Nursing Data Mart Survey	0917-0036	Public Health Nursing (PHN) Data Mart Survey Questions
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Special Care Unit (SCU) Patient Experience Survey
Tele-Behavioral Health Center of Excellence (TBHCE) Survey	9017-0036	LHP Behaviorial Health Training Needs Survey
Telebehavioral Health Patient Satisfaction Survey	0917-0036	Telebehavioral Health Patient Satisfaction Survey
User satisfaction data collection for the IHS OIT NDW	0917-0036	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	2, 1, 3, 4, 5, 6, 7, 8	Behavioral Health Patient Satisfaction Survey ,   Dental Patient Satisfaction Survey ,   Laboratory Patient Satisfaction Survey ,   Nutrition Services Patient Satisfaction Survey ,   Optometry Patient Satisfaction Survey ,   Pharmacy Patient Satisfaction Survey ,   Physcial Therapy Patient Satisfaction Survey ,   Radiology Patient Satisfaction Survey
We Care Survey, Blackfeet Community Hospital.	0917-0036	We Care Survey, Blackfeet Community Hospital.
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit Indian Health Service
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit, Indian Health Service
We Care Survey, Northern Cheyenne	0917-0036	We Care Patient Satisfaction Survey for Northern Cheyenne
WebTMA Survey	0917-0036	WebTMA Survey
White Earth Dental Clinic Patient Satisfaction Survey	0917-0036	White Earth Dental Clinic Patient Satisfaction Survey
Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	0917-0036	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey
eLearning Hands-on Customer Satisfaction Survey	0917-0036	eLearning Hands-on Customer Satisfaction survey

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ICR Summary of Burden

	Total Request	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	105,000	105,000	0	0	0	0
Annual Time Burden (Hours)	17,500	17,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $25,000

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.     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.     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? No

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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: 01/13/2022

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