[NCCDPHP] Community Health Workers for COVID Response and Resilient Communities’ National Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CHW Survey	Form and Instruction	New	Available
Community Health Workers CHW Survey	Form and Instruction	New	Repair queued
Recipient Survey (English)	Form and Instruction	New	Available
Community Health Workers Recipient Survey	Form and Instruction	New	Repair queued
Att 7a - CHW Survey human subjects document exemption determination.pdf	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 7 - CCR Recipient Survey human subjects document exemption determination.docx	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 6 - 60-day Federal Register Notice.pdf	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 5c - CHW Survey Reminder Email .docx	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 5b - CHW Survey Introductory Email .docx	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 4d - CCR Recipient Survey Reminder.docx	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 4c - CCR Recipient Survey Introductory Email.docx	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 4b- CCR Evaluation Surveys Announcement Email.docx	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 3 - CCR National Evaluation Question Matrix.docx	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 2 - DP21-2109 Logic Model.pdf	Supplementary Document	Uploaded 2023-06-09	Repair queued
Att 1 Authorizing Legislation.pdf	Supplementary Document	Uploaded 2023-06-09	Repair queued
0920-23AH CHW_SS Part B.docx	Supporting Statement B	Uploaded 2023-06-08	Repair queued
0920-23AH CHW_SS Part A_final.docx	Supporting Statement A	Uploaded 2023-06-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
260599	Community Health Workers CHW Survey	Form and Instruction	New	CHW Survey
260599	Community Health Workers CHW Survey	Form and Instruction	New
260598	Community Health Workers Recipient Survey	Form and Instruction	New	Recipient Survey (English)
260598	Community Health Workers Recipient Survey	Form and Instruction	New

ICR Details

OMB Control No: 0920-1411	ICR Reference No: 202306-0920-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-23AH
Title: [NCCDPHP] Community Health Workers for COVID Response and Resilient Communities’ National Evaluation
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/27/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/09/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2026	36 Months From Approved
Responses	390	0	0
Time Burden (Hours)	194	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The evaluation of CDC-RFA-DP21-2109, Community Health Workers for COVID Response and Resilient Communities (CCR), includes: (1) a CCR recipient survey that will be administered to Program Directors of the 68 CCR funded recipients, and (2) a CCR CHW survey that will be administered among CHWs funded by the 68 CCR recipients. CDC will use resulting information to describe the implementation of CCR at the national level; inform future community-based and CHW-led COVID response programs; and, in conjunction with secondary data sources, assess key health outcomes, including COVID-19 vaccination rates among some populations of focus.

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Authorizing Statute(s): 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 64046	10/21/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 37883	06/09/2023
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Community Health Workers CHW Survey	n/a	CHW Survey
Community Health Workers Recipient Survey	n/a	Recipient Survey (English)

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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	390	0	0	390	0	0
Annual Time Burden (Hours)	194	0	0	194	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: This is a New collection.

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Annual Cost to Federal Government: $589,400

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? 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: 06/09/2023

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