42 C.F.R. Subpart B: Sterilization of Persons in Federally Assisted Family Planning Projects

Forms and Documents

Document Name	Status
Form 0937-0166 Information disclosure for sterilization consent forms Form	Modified
Form 0937-0166 Record Keeping for sterilization consent forms Form	New
0937-0166 Supporting Statement Sterilization Consent Form 2009 revised 12.01.2009.doc Supporting Statement A	2009-12-01

IC Document Collections

IC ID	Document Title	Status
7740	Information disclosure for sterilization consent forms Form	Modified
191181	Record Keeping for sterilization consent forms Form	New

ICR Details

OMB Control No: 0937-0166	ICR Reference No: 200911-0937-001
Status: Historical Active	Previous ICR Reference No: 200608-0937-001
Agency/Subagency: HHS/OASH	Agency Tracking No:
Title: 42 C.F.R. Subpart B: Sterilization of Persons in Federally Assisted Family Planning Projects
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/30/2009
	Date Received in OIRA: 11/03/2009
Terms of Clearance: Approved consistent with revised Supporting Statement uploaded on 12/01/2009.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	36 Months From Approved	12/31/2009
Responses	200,000	0	100,000
Time Burden (Hours)	125,000	0	125,000
Cost Burden (Dollars)	0	0	0

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Abstract: These regulations and informed consent procedures are associated with Federally funding sterilization services. Selected consent forms are audited during the site visits and program reviews by Federal programs to ensure compliance with the regulations and protection of individual's rights.

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Authorizing Statute(s): PL: Pub.L. 42 - 241 301 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:
	74 FR 41437	08/17/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 55555	10/28/2009
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Information disclosure for sterilization consent forms	0937-0166	sterlization form
Record Keeping for sterilization consent forms	0937-0166	Sterilization form

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ICR Summary 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	200,000	100,000	0	100,000	0	0
Annual Time Burden (Hours)	125,000	125,000	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The only revision to the form is based on the program change as stated in the supporting statement the entitlement program previously referenced in the Sterilization Consent Form, Aid to Families with Dependent Children (AFDC), utilized by low-income families with dependent children who need federal assistance, has been replaced by a different program with similar aims, Temporary Assistance for Needy Families (TANF). Consequently, the reference to AFDC in the first paragraph of the consent form has been replaced with a reference to TANF.

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Annual Cost to Federal Government: $21,120

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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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: 11/03/2009

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