CMS Health Equity Award – Call for Nominations (CMS-10866)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10866 Health Equity award Nominations	Form and Instruction	New	Repair queued
CMS-10866 Supporting Statement - Part A_.docx	Supporting Statement A	Uploaded 2023-11-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
263665	Health Equity award Nominations	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202311-0938-010
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: OMH
Title: CMS Health Equity Award – Call for Nominations (CMS-10866)
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/27/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	50	0
Time Burden (Hours)	100	0
Cost Burden (Dollars)	0	0

---

Abstract: The CMS Office of Minority Health is announcing an annual call for nominations for the CMS OMH Health Equity Award. This award will recognize organizations that demonstrate they have advanced health equity by designing, Implementing, and operationalizing policies and programs that support health for all the people served by our programs, reducing avoidable differences in health outcomes experienced by people who are underserved, and provided the care and support that CMS enrollees need to thrive.

---

Authorizing Statute(s): US Code: 42 USC 300u Name of Law: General authority of Secretary
  

Citations for New Statutory Requirements: US Code: 42 USC 300u Name of Law: General authority of Secretary

---

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 62088	09/08/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 82379	11/24/2023
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
Health Equity award Nominations	CMS-10866, CMS-10866	CMS Health Equity Nomination Form ,   CMS Health Equity Scoring Rubric

---

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	50	0	0	0	0	50
Annual Time Burden (Hours)	100	0	0	0	0	100
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: $5,623

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.     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: 11/27/2023

---