Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Mental Health and Substance Use Disorders Programs Project

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form B12 Attachment B12 - Program Implementation SSI MMHSUD	Form and Instruction	New	Available
Form B4 Attachment B4 - Program Implementation SSI PMHCA	Form and Instruction	New	Available
Form B4 Program Implementation Semi-Structured Interview (SSI)	Form and Instruction	New	Repair queued
Form B14 Attachment B14 - Community-Based and Other Resources SSI MMHSUD	Form and Instruction	New	Available
Form B6 Attachment B6 - Community-Based and Other Resources SSI PMHCA	Form and Instruction	New	Available
Form B6 Community-based and Other Resources Semi-Structured Interview (SSI)	Form and Instruction	New	Missing upstream
Form B15 Attachment B15 - Champion SSI MMHSUD	Form and Instruction	New	Available
Form B7 Attachment B7 - Champion SSI PMHCA	Form and Instruction	New	Available
Form B7 Champion Semi-Structured Interview	Form and Instruction	New	Repair queued
Form B13 Attachment B13 - Care Coordinator SSI MMHSUD	Form and Instruction	New	Available
Form B5 Attachment B5 - Care Coordinator SSI PMHCA	Form and Instruction	New	Available
Form B5 Care Coordinator Semi-Structured Interview (SSI)	Form and Instruction	New	Repair queued
Form B16 Attachment B16 - Behavioral Health Consultation Provider SSI MMHSUD	Form and Instruction	New	Available
Form B8 Attachment B8 - Behavioral Health Consultation Provider SSI PMHCA	Form and Instruction	New	Available
Form B8 Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction	New	Repair queued
Form B11 Attachment B11 - Program Implementation Survey MMHSUD	Form and Instruction	New	Available
Form B3 Attachment B3 - Program Implementation Survey PMHCA	Form and Instruction	New	Available
Form B3 Program Implementation Survey	Form and Instruction	New	Repair queued
Form B10 Attachment B10 - Practice Level Survey MMHSUD	Form and Instruction	New	Available
Form B2 Attachment B2 - Practice Level Survey PMHCA	Form and Instruction	New	Available
Form B2 Practice-Level Survey	Form and Instruction	New	Repair queued
Form B9 Attachment B9 - Health Professional Survey MMHSUD	Form and Instruction	New	Available
Form B1 Attachment B1 - Health Professional Survey PMHCA	Form and Instruction	New	Available
Form B1 Health Professional Survey	Form and Instruction	New	Available
PC_202410-0906-001_101424_051822_1.pdf	Public Comments	Uploaded 2024-10-14	Repair queued
Jackson_Comment.pdf	Public Comments	Uploaded 2024-07-29	Repair queued
Jackson_Comment Transmittal.pdf	Public Comments	Uploaded 2024-07-29	Repair queued
Hoffman_Comment.pdf	Public Comments	Uploaded 2024-07-29	Repair queued
Hoffman_Comment Transmittal.pdf	Public Comments	Uploaded 2024-07-29	Repair queued
Attachment B17 - Pilot Testing Feedback.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment B17 - Pilot Testing Feedback.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
AG19-001 Expedited Review Approval Letter 7-23-2024.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
AG19-001 Expedited Review Approval Letter 7-23-2024.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A45 - Program Implementation Survey Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A45 - Program Implementation Survey Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A44 - Program Implementation Survey Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A44 - Program Implementation Survey Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A43 - Program Implementation Survey Email Notification - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A43 - Program Implementation Survey Email Notification - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A42 - Program Implementation SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A42 - Program Implementation SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A41 - Program Implementation SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A41 - Program Implementation SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A40 - Program Implementation SSI Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A40 - Program Implementation SSI Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A39 - Practice Survey Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A39 - Practice Survey Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A38 - Practice Survey Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A38 - Practice Survey Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A37 - Practice Survey Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A37 - Practice Survey Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A36 - Practice Survey Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A36 - Practice Survey Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A35 - Practice Survey Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A35 - Practice Survey Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A34 - Practice-Level Survey Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A34 - Practice-Level Survey Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A33 - Health Professional Survey Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A33 - Health Professional Survey Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A32 - Health Professional Survey Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A32 - Health Professional Survey Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A31 - Health Professional Survey Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A31 - Health Professional Survey Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A30 - Health Professional Survey Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A30 - Health Professional Survey Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Missing upstream
Attachment A29 - Health Professional Survey Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A29 - Health Professional Survey Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A28 - Health Professional Survey Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A28 - Health Professional Survey Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A27 - Community Resources SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A27 - Community Resources SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A26 - Community Resources SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A26 - Community Resources SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A25 - Community Resources SSI Participation - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A25 - Community Resources SSI Participation - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A24 - Community Resources SSI Participation - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A24 - Community Resources SSI Participation - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A23 - Community Resources SSI Email Notification - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A23 - Community Resources SSI Email Notification - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A22 - Community Resources SSI Email Notification - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A22 - Community Resources SSI Email Notification - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A21 - Champion SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A21 - Champion SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A20 - Champion SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A20 - Champion SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Missing upstream
Attachment A19 - Champion SSI Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A19 - Champion SSI Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A18 - Champion SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A18 - Champion SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A17 - Champion SSI Email Notification - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A17 - Champion SSI Email Notification - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A16 - Champion SSI Email Notification - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A16 - Champion SSI Email Notification - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A15 - Care Coordinator SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A15 - Care Coordinator SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A14 - Care Coordinator SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A14 - Care Coordinator SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A13 - Care Coordinator SSI Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A13 - Care Coordinator SSI Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A12 - Care Coordinator SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A12 - Care Coordinator SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Missing upstream
Attachment A11 - Care Coordinator SSI Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A11 - Care Coordinator SSI Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A10 - Care Coordinator SSI Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A10 - Care Coordinator SSI Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A9 - Behavioral Health Consultation Provider SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A9 - Behavioral Health Consultation Provider SSI Reminder Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A8 - Behavioral Health Consultation Provider SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A8 - Behavioral Health Consultation Provider SSI Reminder Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A7 - Behavioral Health Consultation Provider SSI Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A7 - Behavioral Health Consultation Provider SSI Participation Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A6 - Behavioral Health Consultation Provider SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A6 - Behavioral Health Consultation Provider SSI Participation Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A5 - Behavioral Health Consultation Provider SSI Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A5 - Behavioral Health Consultation Provider SSI Notification Email - Awardee_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A4 - Behavioral Health Consultation Provider SSI Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A4 - Behavioral Health Consultation Provider SSI Notification Email - JBS_Final.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A2_60 Day FRN - PMHCA and MMHSUDS.pdf	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A2_60 Day FRN - PMHCA and MMHSUDS.pdf	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A3 - 60-day FRN Comments and Responses 7-31-24.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A3 - 60-day FRN Comments and Responses 7-31-24.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Attachment A1 - Legislation_Final OMB.docx	Supplementary Document	Uploaded 2024-10-09	Available
Attachment A1 - Legislation_Final OMB.docx	Supplementary Document	Uploaded 2024-10-09	Repair queued
Supporting Statement B_09092024.docx	Supporting Statement B	Uploaded 2024-10-09	Available
Supporting Statement B_09092024.docx	Supporting Statement B	Uploaded 2024-10-09	Repair queued
Supporting Statement A_10162024.docx	Supporting Statement A	Uploaded 2024-10-16	Repair queued
Supporting Statement A_09162024.docx	Supporting Statement A	Uploaded 2024-10-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
271506	Program Implementation Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B12 - Program Implementation SSI MMHSUD
271506	Program Implementation Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B4 - Program Implementation SSI PMHCA
271506	Program Implementation Semi-Structured Interview (SSI)	Form and Instruction	New
271505	Community-based and Other Resources Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B14 - Community-Based and Other Resources SSI MMHSUD
271505	Community-based and Other Resources Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B6 - Community-Based and Other Resources SSI PMHCA
271505	Community-based and Other Resources Semi-Structured Interview (SSI)	Form and Instruction	New
271504	Champion Semi-Structured Interview	Form and Instruction	New	Attachment B15 - Champion SSI MMHSUD
271504	Champion Semi-Structured Interview	Form and Instruction	New	Attachment B7 - Champion SSI PMHCA
271504	Champion Semi-Structured Interview	Form and Instruction	New
271503	Care Coordinator Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B13 - Care Coordinator SSI MMHSUD
271503	Care Coordinator Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B5 - Care Coordinator SSI PMHCA
271503	Care Coordinator Semi-Structured Interview (SSI)	Form and Instruction	New
271502	Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B16 - Behavioral Health Consultation Provider SSI MMHSUD
271502	Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction	New	Attachment B8 - Behavioral Health Consultation Provider SSI PMHCA
271502	Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction	New
271501	Program Implementation Survey	Form and Instruction	New	Attachment B11 - Program Implementation Survey MMHSUD
271501	Program Implementation Survey	Form and Instruction	New	Attachment B3 - Program Implementation Survey PMHCA
271501	Program Implementation Survey	Form and Instruction	New
271500	Practice-Level Survey	Form and Instruction	New	Attachment B10 - Practice Level Survey MMHSUD
271500	Practice-Level Survey	Form and Instruction	New	Attachment B2 - Practice Level Survey PMHCA
271500	Practice-Level Survey	Form and Instruction	New
271499	Health Professional Survey	Form and Instruction	New	Attachment B9 - Health Professional Survey MMHSUD
271499	Health Professional Survey	Form and Instruction	New	Attachment B1 - Health Professional Survey PMHCA
271499	Health Professional Survey	Form and Instruction	New

ICR Details

OMB Control No: 0906-0105	ICR Reference No: 202410-0906-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Mental Health and Substance Use Disorders Programs Project
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 without change	Conclusion Date: 12/06/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/10/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2027	36 Months From Approved
Responses	29,880	0	0
Time Burden (Hours)	10,026	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection will be used to evaluate the Pediatric Mental Health Care Access (PMHCA) Program and the Screening and Treatment for Maternal Mental Health and Substance Use Disorders (MMHSUD) Program. The evaluation will be used to study the efforts of PMHCA and MMHSUD programs to achieve key outcomes (e.g., increase in access to behavioral health services; HPs trained; identification of community-based resources, including counselors or family service providers) and to measure whether and to what extent awardee programs are associated with changes in these outcomes. The evaluation will examine changes over time within and/or across PMHCA and MMHSUD programs, regarding PMHCA- and MMHSUD-enrolled/participating HPs’ and practices’ (1) capacity to address patients’ behavioral health and access to behavioral health care, through screening, assessment, treatment, and referral for behavioral health conditions, and (2) use of program services (i.e., consultation, care coordination, training).

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Authorizing Statute(s): PL: Pub.L. 114 - 255 10002 Name of Law: 21st Century Cures Act
   PL: Pub.L. 117 - 2 2712 Name of Law: American Rescue Plan Act
   PL: Pub.L. 117 - 159 11005 Name of Law: Bipartisan Safer Communities Act
   US Code: 42 USC 247b-13a Name of Law: Public Health Service 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:
	89 FR 46143	05/28/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 81920	10/09/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	B16, B8	Attachment B8 - Behavioral Health Consultation Provider SSI PMHCA ,   Attachment B16 - Behavioral Health Consultation Provider SSI MMHSUD
Care Coordinator Semi-Structured Interview (SSI)	B13, B5	Attachment B5 - Care Coordinator SSI PMHCA ,   Attachment B13 - Care Coordinator SSI MMHSUD
Champion Semi-Structured Interview	B7, B15	Attachment B7 - Champion SSI PMHCA ,   Attachment B15 - Champion SSI MMHSUD
Community-based and Other Resources Semi-Structured Interview (SSI)	B14, B6	Attachment B6 - Community-Based and Other Resources SSI PMHCA ,   Attachment B14 - Community-Based and Other Resources SSI MMHSUD
Health Professional Survey	B1, B9	Attachment B1 - Health Professional Survey PMHCA ,   Attachment B9 - Health Professional Survey MMHSUD
Practice-Level Survey	B2, B10	Attachment B2 - Practice Level Survey PMHCA ,   Attachment B10 - Practice Level Survey MMHSUD
Program Implementation Semi-Structured Interview (SSI)	B4, B12	Attachment B4 - Program Implementation SSI PMHCA ,   Attachment B12 - Program Implementation SSI MMHSUD
Program Implementation Survey	B3, B11	Attachment B3 - Program Implementation Survey PMHCA ,   Attachment B11 - Program Implementation Survey MMHSUD

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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	29,880	0	0	29,880	0	0
Annual Time Burden (Hours)	10,026	0	0	10,026	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: $804,666

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: 10/10/2024

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