Survey to Inform the Children's Health Insurance Program (CHIP) National Outreach & Education Campaign

Forms and Documents

Document Name	Status
Form CMS-10318 Screening Form and Instruction	New
Form CMS-10318 Survey Form and Instruction	New
CMS-10318.Supporting Statement Parts A and B - FINAL_508COMPL.pdf Supporting Statement B	2010-08-09
CMS-10318.Supporting Statement Part A - FINAL_508COMPL.pdf Supporting Statement A	2010-08-09

IC Document Collections

IC ID	Document Title	Status
194460	Screening Form and Instruction	New
194459	Survey Form and Instruction	New

ICR Details

OMB Control No: 0938-1112	ICR Reference No: 201008-0938-021
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Survey to Inform the Children's Health Insurance Program (CHIP) National Outreach & Education Campaign
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: 10/29/2010
	Date Received in OIRA: 08/30/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved
Responses	5,550	0	0
Time Burden (Hours)	1,233	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law 111-3) reauthorized the Children's Health Insurance Program (CHIP) through FY 2013. It will preserve coverage for the millions of children who rely on CHIP today and provide the resources for States to reach millions of additional uninsured children. This legislation will help ensure the health and well-being of our nation's children. To support this legislation and to help people who would benefit from CHIP make more informed decisions, CMS will be conducting outreach. The outreach will employ numerous communications channels to educate people who would benefit from CHIP concerning the program benefits, eligibility and enrollment requirements, utilization, and retention. As part of the outreach, CMS will seek to increase awareness, enrollment and retention in CHIP for the eligible audiences. The primary target audience for the outreach includes parents and guardians of potentially eligible children as well as pregnant women. Secondary audiences are information intermediaries including State, local, and tribal governments, educators (including non-parental caregivers) health care providers /social workers, national and local partners. The challenge is reaching the population segments that have access barriers to information including language, literacy, location, and culture to understand health insurance. To support the outreach and education, CMS needs to conduct survey research to be able to effectively reach the target audiences.

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Authorizing Statute(s): PL: Pub.L. 111 - 3 Title II Name of Law: Children's Health Insurance Program Reauthorization Act of 2009
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 3 Tile II Name of Law: Children's Health Insurance Program Reauthorization Act of 2009

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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:
	75 FR 27787	05/18/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 44969	07/30/2010
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
Survey	CMS-10318, CMS-10318CMS Chip Medicaid Survey Final 10_19_10	CHIP Survey ,   CMS-10318CMS Chip Medicaid Survey Final 10_19_10
Screening	CMS-10318, CMS-10318	CHIP Survey ,   CMS Chip Medicaid Survey Final 10_19_10

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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	5,550	0	5,550	0	0	0
Annual Time Burden (Hours)	1,233	0	1,233	0	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: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $406,093

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: 08/30/2010

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