[NCCDPHP] WISEWOMAN National Program Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1279 Key Administrative Staff Discussion Guide	Form	Modified	Available
Form 0920-1279 Site Visit Discussion Guide - Administrators	Form	Modified	Repair queued
Form 0920-1279 Program Survey	Form	Modified	Available
Form 0920-1279 Program Survey	Form	Modified	Repair queued
30dy231279.published.pdf	Supplementary Document	Uploaded 2022-12-13	Repair queued
Attachment G Expedited Review Approved_ IRB #612MPR19.pdf	Supplementary Document	Uploaded 2022-12-05	Repair queued
Attachment F1 0920-1279 60 day Aug22-2022.pdf	Supplementary Document	Uploaded 2022-12-05	Repair queued
Attachment E Consent form.docx	Supplementary Document	Uploaded 2022-12-05	Repair queued
Attachment B Public Health Service Act.pdf	Supplementary Document	Uploaded 2019-10-10	Repair queued
Attachment A BCC Mortality Prev Act of 1990.pdf	Supplementary Document	Uploaded 2019-10-10	Repair queued
Support Statement B WISEWOMAN National Eval.docx	Supporting Statement B	Uploaded 2022-12-13	Repair queued
Support Statement A WISEWOMAN National Eval 11_30_22.docx	Supporting Statement A	Uploaded 2022-12-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
238086	Innovation Site Visit Discussion Guide - Providers	Other-Discussion Guide	Unchanged
238085	Site Visit Discussion Guide - Providers	Other-Discussion Guide	Unchanged
238084	Innovation Site Visit Discussion Guide - Support Staff	Other-Discussion Guide	Unchanged
238083	Site Visit Discussion Guide - Support Staff	Other-Discussion Guide	Unchanged
238082	Innovation Site Visit Discussion Guide - Partners	Other-Discussion Guide	Unchanged
238081	Site Visit Discussion Guide - Partners	Other-Discussion Guide	Unchanged
238080	Innovation Site Visit Discussion Guide - Administrators	Other-Discussion Guide	Modified
238079	Site Visit Discussion Guide - Administrators	Form	Modified	Key Administrative Staff Discussion Guide
238079	Site Visit Discussion Guide - Administrators	Form	Modified
238078	Program Survey	Form	Modified	Program Survey
238078	Program Survey	Form	Modified

ICR Details

OMB Control No: 0920-1279	ICR Reference No: 202211-0920-004
Status: Historical Active	Previous ICR Reference No: 201910-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1279
Title: [NCCDPHP] WISEWOMAN National Program Evaluation
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/17/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/14/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2026	36 Months From Approved	03/31/2023
Responses	80	0	80
Time Burden (Hours)	84	0	84
Cost Burden (Dollars)	4,382	0	4,382

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Abstract: The purpose of this information collected under this OMB request provides the data necessary to support a thorough evaluation of the WISEWOMAN program and meet the specific goals of the evaluation. Underlying the evaluation of WISEWOMAN is the program logic model (Figure A.1). This framework was used to identify data elements related to program implementation and outcomes that are required in addition to MDEs, which are collected on an ongoing basis separately from these proposed data activities and capture individual-level information about participants’ outcomes, receipt of services, and demographics. Results from the evaluation efforts will provide information about the annual and long-term performance of the program and help determine progress toward WISEWOMAN goals and outcomes. In addition, the study will document emerging, promising, and best practices that could be replicated and scaled up.

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Authorizing Statute(s): PL: Pub.L. 101 - 354 1501 Name of Law: Breast and Cervical Cancer Mortality Prevention Act of 1990
   US Code: 42 USC 241 Name of Law: PHSA
  

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:
	87 FR 51429	08/22/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 76051	12/12/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Innovation Site Visit Discussion Guide - Administrators
Innovation Site Visit Discussion Guide - Partners
Innovation Site Visit Discussion Guide - Providers
Innovation Site Visit Discussion Guide - Support Staff
Program Survey	0920-1279	Program Survey
Site Visit Discussion Guide - Administrators	0920-1279	Key Administrative Staff Discussion Guide
Site Visit Discussion Guide - Partners
Site Visit Discussion Guide - Providers
Site Visit Discussion Guide - Support Staff

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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	80	80	0	0	0	0
Annual Time Burden (Hours)	84	84	0	0	0	0
Annual Cost Burden (Dollars)	4,382	4,382	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: $162,671

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? 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: 12/14/2022

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