WISEWOMAN National Program Evaluation: Implementation Assessment

Forms and Documents

Document Name	Status
Private Sector Form	New
(Private Sector) Awardee Partners Discussion Guide Form	New
(Private Sector) Awardee Partners Network Survey Form	New
Clinical Providers Form	New
Healthy Behavior Support Staff Site Visit Discussion Guide Form	New
Awardee Partners Site Visit Discussion Guide Form	New
Awardee Partners Network Survey Form	New
Awardee Administrators Site Visit Discussion Guide Form	New
Awardee Administrators Network Survey Form	New
Awardee Administrators Program Survey Form	New
Attachment B proposed outcomes and measures_5 27 2015.docx Supplementary Document	2015-05-27
Attachment B proposed outcomes and measures.docx Supplementary Document	2014-12-04
Attachment E5 Consent form.docx Supplementary Document	2014-12-04
IRB exempt.pdf Supplementary Document	2014-12-04
Attachment F2 Summary of Public Comments.docx Supplementary Document	2014-12-04
Attachment F1 Federal Register Notice.pdf Supplementary Document	2014-12-04
Attachment A1 A2 authorizing legislation.pdf Supplementary Document	2014-12-04
WISEWOMAN OMB Part B_11 07 2014.docx Supporting Statement B	2014-12-04
WISEWOMAN OMB Part A_5 27 2015.docx Supporting Statement A	2015-05-27

IC Document Collections

IC ID	Document Title	Status
214159	Private Sector Form	New
214158	(Private Sector) Awardee Partners Discussion Guide Form	New
214157	(Private Sector) Awardee Partners Network Survey Form	New
214155	Clinical Providers Form	New
214154	Healthy Behavior Support Staff Site Visit Discussion Guide Form	New
214153	Awardee Partners Site Visit Discussion Guide Form	New
214152	Awardee Partners Network Survey Form	New
214151	Awardee Administrators Site Visit Discussion Guide Form	New
214150	Awardee Administrators Network Survey Form	New
214149	Awardee Administrators Program Survey Form	New

ICR Details

OMB Control No: 0920-1068	ICR Reference No: 201412-0920-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 414AUI
Title: WISEWOMAN National Program Evaluation: Implementation Assessment
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: 05/29/2015
	Date Received in OIRA: 12/22/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved
Responses	219	0	0
Time Burden (Hours)	132	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Approval is requested for 3 years to conduct a program implementation assessment of the WISEWOMAN program (Well-Integrated Screening and Evaluation for Women Across the Nation). The proposed new information collection will gather process data to improve understanding of how WISEWOMAN awardees implement program activities. The information collection includes a program survey, a network survey, and site visits.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
   PL: Pub.L. 101 - 354 300k Name of Law: Breast and Cervical Cancer Mortality Prevention Act of 1990
  

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:
	79 FR 50653	08/25/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 74097	12/15/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
Awardee Administrators Program Survey	none	Awardee Administrators Program Survey
Awardee Partners Network Survey	none	Awardee Partners Network Survey
Awardee Administrators Site Visit Discussion Guide	none	Discussion Guide
Awardee Administrators Network Survey	none	Administrators Network Survey
Healthy Behavior Support Staff Site Visit Discussion Guide	none	Healthy Behavior Staff Discussion Guide
Clinical Providers	none	Clinical Provider Partners Discussion Guide
Awardee Partners Site Visit Discussion Guide	none	Awardee Partners Site Visit
(Private Sector) Awardee Partners Network Survey	none	Awardee Partners Network Survey (Private Sector)
(Private Sector) Awardee Partners Discussion Guide	none	Discussion Guide
Private Sector	none	Discussion Guide

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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	219	0	0	219	0	0
Annual Time Burden (Hours)	132	0	0	132	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 data collection request.

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Annual Cost to Federal Government: $150,000

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: 12/22/2014

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