OMHA Annual Appellant Climate Survey

Forms and Documents

Document Name	Status
0990-0330_Appellant study_Section B Statistical Methods OMB 100611.docx Supporting Statement B	2011-10-17
0990-0330_Revision Supporting Statement FINAL 051611.docx Supporting Statement A	2011-10-17

IC Document Collections

IC ID	Document Title	Status
184626	Beneficiaries Other-Survey	Modified
184625	Health Care Providers and Suppliers Other-Survey	Modified

ICR Details

OMB Control No: 0990-0330	ICR Reference No: 201110-0990-001
Status: Historical Active	Previous ICR Reference No: 200804-0990-003
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: OMHA Annual Appellant Climate Survey
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/30/2011
	Date Received in OIRA: 10/17/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved
Responses	400	0	0
Time Burden (Hours)	73	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Office of Medicare Hearings and Appeals (OMHA)requests a three year programmatic clearance from the OMB to conduct customer research through external surveys by means of telephone interviews and web-based suveys. The proposed information collection request covers all types of OMHA appellants, with a primary focus on the three appellant types who receive benefits from OMHA-beneficiares, providers, and suppliers.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
   EO: EO 12862 Name/Subject of EO: September 11, 1993
  

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:
	76 FR 35442	06/17/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 59129	09/23/2011
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
Health Care Providers and Suppliers
Beneficiaries

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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	400	0	0	0	0	400
Annual Time Burden (Hours)	73	0	0	0	0	73
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: $175,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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]? 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? 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: 10/17/2011

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