Estimating the Gap Between the Needs of Children and Health Coverage and Benefits Through Implementation of the Affordable Care Act

Forms and Documents

Document Name	Status
Form 1 Title V Survey Form and Instruction	New
Supporting Stmt B_mr v2.docx Supporting Statement B	2013-07-31
FAQ Title V Survey v2_mr.docx Supplementary Document	2013-07-31
authorization and appropriations.mht Supplementary Document	2013-07-31
4 Research Determination.pdf Supplementary Document	2013-07-31
3. Summary Pretest Comments.docx Supplementary Document	2013-07-31
2. Reconciliation of FRN Comments_mr.docx Supplementary Document	2013-07-31
5.e. Reminder Email_mr.docx Supplementary Document	2013-07-31
5.b. Cover E-mail_mr.docx Supplementary Document	2013-07-31
5.a. Prenotification E-mail_mr.docx Supplementary Document	2013-07-31
Supporting Stmt A_mr.docx Supporting Statement A	2013-08-01

IC Document Collections

IC ID	Document Title	Status
208301	Title V Survey Form and Instruction	New

ICR Details

OMB Control No: 0915-0369	ICR Reference No: 201308-0915-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No: 20204
Title: Estimating the Gap Between the Needs of Children and Health Coverage and Benefits Through Implementation of the Affordable Care Act
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 with change	Conclusion Date: 10/24/2013
	Date Received in OIRA: 08/20/2013
Terms of Clearance: Approved consistent with the updated survey instrument.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2016	36 Months From Approved
Responses	52	0	0
Time Burden (Hours)	1,872	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The proposed data collection form has been developed to collect health care services budget information from Title V MCH Block Grant recipients to better understand the types of direct services currently provided by Title V MCH programs. The respondents to the survey will be the Title V Program Directors in the States, the District of Columbia and Puerto Rico.

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Authorizing Statute(s): PL: Pub.L. 101 - 239 501 Name of Law: Maternal and Child Health Services Block Grant
  

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:
	78 FR 954	01/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 48439	08/08/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Title V Survey	1	survey

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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	52	0	0	52	0	0
Annual Time Burden (Hours)	1,872	0	0	1,872	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 information collection.

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Annual Cost to Federal Government: $49,889

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]? Yes

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: 08/20/2013

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