National Healthy Start Evaluation and Quality Assurance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4_Revised 0915-0338_MCHB_HSMED_Parent Child Form_Redline_03052025	Form and Instruction	Modified	Available
Form 4_Revised Parent/Child Form	Form and Instruction	Modified	Repair queued
Form 3_Revised Prenatal Form (Revised)	Form and Instruction	Unchanged	Available
Form 3 Prenatal Form	Form and Instruction	Unchanged	Available
Form 3 Prenatal Form	Form and Instruction	Unchanged	Repair queued
Form 1 Demographic Form	Form and Instruction	Modified	Available
Form 2 Background Form	Form and Instruction	Modified	Available
Form 2 Background and Demographic Information Form	Form and Instruction	Modified	Repair queued
0915-0338_MCHB_OMB Nonsubstantive Change Request_03052025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-14	Available
0915-0338_MCHB_OMB Nonsubstantive Change Request_03052025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-14	Repair queued
0915-0338_MCHB_HSMED_Implementation Guide ParentChild Form_Redline_03052025.docx	Supplementary Document	Uploaded 2025-03-14	Available
0915-0338_MCHB_HSMED_Implementation Guide ParentChild Form_Redline_03052025.docx	Supplementary Document	Uploaded 2025-03-14	Repair queued
0915-0338_MCHB_HSMED_Implementation Guide Demographic Form_Redline_03052025.docx	Supplementary Document	Uploaded 2025-03-14	Available
0915-0338_MCHB_HSMED_Implementation Guide Demographic Form_Redline_03052025.docx	Supplementary Document	Uploaded 2025-03-14	Repair queued
Healthy Start Data Collection Forms_OMB NonSubstantive Change Request_Nov2024.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-12-18	Available
Healthy Start Data Collection Forms_OMB NonSubstantive Change Request_Nov2024.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-12-18	Repair queued
Parent Child Form- MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-20	Available
Parent Child Form- MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-20	Repair queued
Demographic_Form- MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-18	Available
Demographic_Form- MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-18	Repair queued
Demographic_Form- MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-18	Available
Demographic_Form- MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-18	Repair queued
Prenatal Form-MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-18	Repair queued
Prenatal Form-MCHB- Healthy Start Eval and Quality-0915-0338- 6.18.24.pdf	Supplementary Document	Uploaded 2024-06-18	Repair queued
MCHB- Healthy Start Evaluation and Quality Assurance NSC- 0915-0338- 06.18.24.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-06-18	Available
MCHB- Healthy Start Evaluation and Quality Assurance NSC- 0915-0338- 06.18.24.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-06-18	Repair queued
Healthy Start Data Collection Forms_OMB NonSubstantive Change Request_Feb2024.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-22	Repair queued
Healthy Start Data Collection Forms_OMB NonSubstantive Change Request_Feb2024.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-22	Repair queued
Revised Supporting Statement _0915-0338_OIRA-07.21.23 rev 9.5.23_clean.docx	Supporting Statement A	Uploaded 2023-09-12	Available
Revised Supporting Statement _0915-0338_OIRA-07.21.23 rev 9.5.23_clean.docx	Supporting Statement A	Uploaded 2023-09-12	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
211289	Parent/Child Form	Form and Instruction	Modified	0915-0338_MCHB_HSMED_Parent Child Form_Redline_03052025
211289	Parent/Child Form	Form and Instruction	Modified
211288	Prenatal Form	Form and Instruction	Unchanged	Prenatal Form (Revised)
211288	Prenatal Form	Form and Instruction	Unchanged	Prenatal Form
211288	Prenatal Form	Form and Instruction	Unchanged
195559	Background and Demographic Information Form	Form and Instruction	Modified	Demographic Form
195559	Background and Demographic Information Form	Form and Instruction	Modified	Background Form
195559	Background and Demographic Information Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0338	ICR Reference No: 202503-0915-001
Status: Active	Previous ICR Reference No: 202412-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: National Healthy Start Evaluation and Quality Assurance
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/15/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2026	09/30/2026	09/30/2026
Responses	106,050	0	106,050
Time Burden (Hours)	48,480	0	48,480
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this ongoing monitoring and evaluation is to assess Healthy Start (HS) progress towards meeting its performance goals. Results from monitoring and evaluation efforts will provide actionable evidence to support the improvement, sustainability, replication, and dissemination of the program. The information collected will be used to obtain consistent information across all 100 grantees about HS, its participants, and its outcomes. Respondents include pregnant women and women of reproductive age that were served by HS and HS staff. This revision seeks to reduce the burden of data collection on grantees and program participants, as well as to focus the evaluation more clearly on progress towards meeting performance goals regarding program impact. In the process, this will ensure that collected data is meaningful for monitoring and evaluation, and that previously separate data systems can be streamlined, thus improving efficiency.

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Authorizing Statute(s): PL: Pub.L. 110 - 339 122 Name of Law: Healthy Start Reauthorization Act of 2007
   US Code: 42 USC 254c-8 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:
	87 FR 64065	10/21/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 10358	02/17/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Background and Demographic Information Form	1 , 2	Background Form ,   Demographic Form
Parent/Child Form	4_Revised	0915-0338_MCHB_HSMED_Parent Child Form_Redline_03052025
Prenatal Form	3, 3_Revised	Prenatal Form ,   Prenatal Form (Revised)

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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	106,050	106,050	0	0	0	0
Annual Time Burden (Hours)	48,480	48,480	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:

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Annual Cost to Federal Government: $204,806

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

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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: 03/28/2025

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