SHIP-SMP Survey of One-on-One Assistance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
SHIP-SMP Survey of One-on-One Assistance	Form and Instruction	Modified	Repair queued
0057 Supporting Statement Part B One on One Final V2 clean.docx	Supporting Statement B	Uploaded 2023-07-19	Repair queued
SOGI Data Collection Policy - ICR OMB Supplemental 2023.pdf	Supplementary Document	Uploaded 2023-07-19	Repair queued
0057 Supporting Statement (1 on 1 Assistance) FINAL V2 Clean.docx	Supporting Statement A	Uploaded 2023-07-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
225703	SHIP-SMP Survey of One-on-One Assistance	Form and Instruction	Modified

ICR Details

OMB Control No: 0985-0057	ICR Reference No: 202306-0985-002
Status: Received in OIRA	Previous ICR Reference No: 202006-0985-004
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: SHIP-SMP Survey of One-on-One Assistance
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: 07/21/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2023
Responses	800	800
Time Burden (Hours)	80	80
Cost Burden (Dollars)	0	0

---

Abstract: Abstract (2000 characters maximum) The information obtained from this survey will be used by federal and regional employees of the Administration for Community Living (ACL), part of the Department of Health and Human Services. Specifically, the information will be used to assess customer satisfaction with one-on-one assistance services delivered by ACL’s SHIP and SMP programs. The results of the survey will be used to assess the need for overall agency improvements, including the reallocation of resources, revisions to certain agency processes and policies, and/or development of guidance related to the agency’s customer services. The results of the survey could also lead to improvements for individual Medicare beneficiaries, as improved customer service by the agency will lead to more appropriate Medicare choices for individual citizens, leading to monetary savings for both the individual and the SHIP/SMP program. Ultimately, these changes should improve the services ACL provides to the public. In addition, ACL will use this data to fulfill the requirements of the Government Performance and Results Modernization Act of 2010 (GPRAMA; Pub.L. 111-352). The GPRA Modernization Act requires ACL to report annually on their progress towards achieving specific performance goals. Results from this survey will help to determine new performance goals and assess existing goals.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 10116	02/16/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 43357	07/07/2023
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
SHIP-SMP Survey of One-on-One Assistance	NA	1-on-1 Assistance Survey

---

ICR Summary of Burden

table that charts list 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	800	800	0	0	0	0
Annual Time Burden (Hours)	80	80	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:

---

Annual Cost to Federal Government: $175,237

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

---

Common Form ICR:  No

---

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: 07/21/2023

---