Maternal, Infant and Early Childhood Home Visiting Program Information System

Forms and Documents

Document Name	Status
Form 3 Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures Form and Instruction	New
Form 1 Home Visiting Program Information System Form and Instruction	Unchanged
Tribal MIECHV Consultation Particpants List.docx Supplementary Document	2014-05-27
Tribal MIECHV Benchmark Areas and Constructs.docx Supplementary Document	2014-05-27
B - Benchmark Areas and Constructs.docx Supplementary Document	2012-08-14
H - Participant list - State Panel for Review of Data Reporting Forms.docx Supplementary Document	2012-08-14
G - Participant list HHS-Model developer Forum.docx Supplementary Document	2012-08-14
F - HV Form 2 - Public Comments final 6.19.2012.pdf Supplementary Document	2012-08-14
E - HV Form 1 - Public Comments - Consolidated tables A TO G final 6.19.2012.pdf Supplementary Document	2012-08-14
A - SSA Title V Section 511.docx Supplementary Document	2012-08-14
Supporting Statement.docx Supporting Statement A	2014-05-27

IC Document Collections

IC ID	Document Title	Status
211723	Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures Form and Instruction	New
203751	Home Visiting Program Information System Form and Instruction	Unchanged

ICR Details

OMB Control No: 0915-0357	ICR Reference No: 201404-0915-006
Status: Historical Active	Previous ICR Reference No: 201208-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Maternal, Infant and Early Childhood Home Visiting Program Information 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: 07/14/2014
	Date Received in OIRA: 05/28/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	36 Months From Approved	10/31/2015
Responses	106	0	81
Time Burden (Hours)	88,614	0	76,739
Cost Burden (Dollars)	0	0	0

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Abstract: The Health Resources and Services Administration and the Administration for Children and Families are seeking approval for 3 data collection instruments-2 currently-approved requiring new approval (Home Visiting Forms 1 & 2), and one new tool (Home Visiting Form 3). The Home Visiting Form 3 is a proposed benchmark data collection instrument for the Tribal MIECHV grantees.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 7101 Name of Law: Patient Protection and Affordable Care Act of 2010
  

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 77690	12/24/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 28931	05/20/2014
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
Home Visiting Program Information System	1, 2	HV Form 1 ,   HV form 2
Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures	3	Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures

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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	106	81	0	25	0	0
Annual Time Burden (Hours)	88,614	76,739	0	11,875	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: The HV Form 3 is a new data collection tool for the MIECHV program information system. It mirrors an already-approved and in use instrument, HV Form 2. As noted earlier, given that Tribal MIECHV grantees are required to report on benchmarks performance data in years 4 and 5 of their grants, it was mutually decided by HRSA and ACF to wait until Tribal grantees were closer to the reporting years to begin reporting performance data hence the current request for OMB approval of the HV Form 3.

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Annual Cost to Federal Government: $806,429

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]? 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: 05/28/2014

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