Testing Experience and Functional Tools Demonstration: Personal Health Record (PHR) User Survey (CMS-10623)

Forms and Documents

Document Name	Status
Form CMS-10623 Personal Health Record (PHR) User Survey Form	New
CMS-10623 - Supporting Statement A [rev 10-04-2016 by OSORA PRA].docx Supporting Statement A	2016-10-04
Appendix D - TEFT OMB 60-day comments.docx Supplementary Document	2016-10-03
OMB Package Supporting Statement B - TEFT PHR User Survey - Sept 2016_508.docx Supporting Statement B	2016-10-03

IC Document Collections

IC ID	Document Title	Status
223740	Personal Health Record (PHR) User Survey Form	New

ICR Details

OMB Control No: 0938-1324	ICR Reference No: 201609-0938-030
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Testing Experience and Functional Tools Demonstration: Personal Health Record (PHR) User Survey (CMS-10623)
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 without change	Conclusion Date: 02/06/2017
	Date Received in OIRA: 10/05/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved
Responses	576	0	0
Time Burden (Hours)	190	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of the beneficiary impact and outcomes evaluation is to quantify the type and magnitude of impacts of the TEFT Demonstration, particularly the experiences related to use of a PHR across different populations enrolled in Medicaid CB-LTSS programs. Our approach relies on the review of each state’s PHR system and the fielding of a PHR User Survey to LTSS program participants and family members related to their experience using the PHR. This will be distributed as an anonymous, web-based survey to the universe of PHR users in each state. The proposed methodology seeks to impose a minimal burden on survey respondents and grantees in order for a successful data collection effort.

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Authorizing Statute(s): None

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:
	81 FR 38187	06/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 66031	09/26/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Personal Health Record (PHR) User Survey	CMS-10623, CMS-10623	Personal Health Record (PHR) User Survey ,   Consent Form

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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	576	0	0	576	0	0
Annual Time Burden (Hours)	190	0	0	190	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: Not applicable since this is a new ICR.

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Annual Cost to Federal Government: $179,237

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]? 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: 10/05/2016

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