Affordable Care Act Tribal Maternal, Infant, and Early Childhood Home Visiting Program Needs Assessment and Plan for Responding to Identified Needs

Forms and Documents

Document Name	Status
Form 1 Assessment and Plan Form and Instruction	Removed
THV SUPSTAT_FINAL.HHS 8-10-16.doc Supporting Statement A	2016-08-10

IC Document Collections

IC ID	Document Title	Status
221921	Tribal MIECHV Form 1 Demographic and Service Utilization Data and Service Instruction	New
221920	Tribal Maternal, Infant, and Early Childhood Home Visiting Implementation Plan Guidance Instruction	New
197233	Assessment and Plan Form and Instruction	Removed

ICR Details

OMB Control No: 0970-0389	ICR Reference No: 201606-0970-002
Status: Historical Active	Previous ICR Reference No: 201104-0970-001
Agency/Subagency: HHS/ACF	Agency Tracking No: OCC
Title: Affordable Care Act Tribal Maternal, Infant, and Early Childhood Home Visiting Program Needs Assessment and Plan for Responding to Identified Needs
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/15/2016
	Date Received in OIRA: 06/15/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/19/2013
Responses	25	0	18
Time Burden (Hours)	16,666	0	1,800
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the information collection is to receive Tribal MIECHV Program grantees’ needs and readiness assessments and plans for implementation so that they can be reviewed and approved as a condition for program implementation, data collection, and evaluation (Implementation Phase, Years 2-5). The Form 1 data are used to help ACF better understand the population receiving services from Tribal MIECHV grantees and the degree to which they are using services, as well as better understanding of the Tribal MIECHV workforce. Overall, this information collection will provide valuable information to HHS that will guide understanding of Tribal MIECHV grantees and the provision of technical assistance to Tribal MIECHV Program grantees.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2951 Name of Law: Patient Protection and Affordable Care Act
  

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:
	80 FR 66008	10/28/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 31641	05/19/2016
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
Tribal MIECHV Form 1 Demographic and Service Utilization Data and Service
Assessment and Plan	1	Needs Assessment and Plan
Tribal Maternal, Infant, and Early Childhood Home Visiting Implementation Plan Guidance

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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	25	18	0	7	0	0
Annual Time Burden (Hours)	16,666	1,800	0	14,866	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: ACF discression

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Annual Cost to Federal Government: $0

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: 06/15/2016

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