Well-Integrated Screening and Evaluation for Women Across the Nation(WISEWOMAN) Reporting System

Forms and Documents

Document Name	Status
Form 0920-0612 Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE Form and Instruction	Modified
0920-0612 Part B_09 24 2013.doc Supporting Statement B	2013-10-21
Attachment 7 Consent Guidance 09 11 2013_TC.doc Supplementary Document	2013-10-30
Attachment 6 WISEWOMAN Programs 08 08 2013.doc Supplementary Document	2013-10-30
Attachment 2b Summary of Public Comments 07 22 2013.doc Supplementary Document	2013-10-29
Attachment 4b Screen Shots of Portal.docx Supplementary Document	2012-12-12
Attachment 4 Screen Shots of Portal 09 24 2013.pdf Supplementary Document	2013-10-29
0920-0612 Part A_09 24 2013.doc Supporting Statement A	2013-10-21

IC Document Collections

IC ID	Document Title	Status
37802	Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE Form and Instruction	Modified
191867	Annual Progress Report Instruction	Modified
191866	Lifestyle Intervention Minimum Data Elements (MDEs) Instruction	Removed

ICR Details

OMB Control No: 0920-0612	ICR Reference No: 201310-0920-006
Status: Historical Active	Previous ICR Reference No: 201301-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 20700
Title: Well-Integrated Screening and Evaluation for Women Across the Nation(WISEWOMAN) Reporting System
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/02/2013
	Date Received in OIRA: 10/30/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved	01/31/2014
Responses	63	0	126
Time Burden (Hours)	1,344	0	1,680
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC plans to collect information from 21 WISEWOMAN program awardees. In 2013 new cooperative agreements were awarded with modified reporting requirements that reflect CDC's increased emphasis on program outcomes. The information collection consists of grantee progress reports and minimum data elements (MDE) that describe the screening, assessment, and lifestyle intervention services provided to women through the WISEWOMAN program.

---

Authorizing Statute(s): PL: Pub.L. 101 - 354 300n-4a Name of Law: The Breast and Cervical Cancer Mortality Prevention Act of 1990
   US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 31554	05/24/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 64502	10/29/2013
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE	0920-0612, 0920-0612	Attachment 3a WISEWOMAN MDE Version 9 ,   Attachment 3b Summary of MDE Changes
Annual Progress Report
Lifestyle Intervention Minimum Data Elements (MDEs)

---

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	63	126	0	-42	-21	0
Annual Time Burden (Hours)	1,344	1,680	0	-336	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The overall burden will decrease due to a reduction in the frequency of progress reporting, from twice per year to once per year. The estimated burden per response for the progress report will not change. The estimated burden for MDE reporting will not change.

---

Annual Cost to Federal Government: $372,198

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? Yes

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

---

Common Form ICR:  No

---

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: 10/30/2013

---