Project NICE: Navigating Insurance Coverage Expansion

Forms and Documents

Document Name	Status
Form 0920 Att 7_Participant Enrollment Form Form	New
Form 0920- Att 6_Informed Consent Form Form	New
Form 0920- Att 5_Participant Eligiility Form Form	New
Att 2a PublicComment.pdf Supplementary Document	2018-06-20
Att 8 PIA Project NICE 4-30-18_OCISO final.pdf Supplementary Document	2018-06-19
Att 4 UCM IRB approval.pdf Supplementary Document	2018-06-19
Att 3 Project Determination_NICE_061917 (002) Fehrs signed.pdf Supplementary Document	2018-06-19
Att 2 60-day FRN.docx.pdf Supplementary Document	2018-06-19
Att 1 Auth Legislation.docx Supplementary Document	2018-06-19
SSB.17AUZ.docx Supporting Statement B	2018-06-19
SSA 17AUZ_062618.docx Supporting Statement A	2018-06-26

IC Document Collections

IC ID	Document Title	Status
231864	Att 7_Participant Enrollment Form Form	New
231856	Att 6_Informed Consent Form Form	New
231854	Att 5_Participant Eligiility Form Form	New

ICR Details

OMB Control No: 0920-1239	ICR Reference No: 201806-0920-009
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-17AUZ
Title: Project NICE: Navigating Insurance Coverage Expansion
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: 07/25/2018
	Date Received in OIRA: 06/27/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	36 Months From Approved
Responses	3,500	0	0
Time Burden (Hours)	875	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This project will implement and evaluate a structural intervention-point of care, in-person health insurance enrollment assistance at the end of an HIV testing session among eligible Black and Hispanic MSM and Transgender persons age 18 and older living in Chicago, Illinois. Process and outcome data will measure the impact of the intervention on linkage to and retention in HIV-related care, referrals to HIV-associated services, and health outcomes. Cost data will also be collected to assess intervention efficacy.

---

Authorizing Statute(s): US Code: 42 USC 241(k) Name of Law: Research and Investigation
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 52302	11/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 28232	06/18/2018
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Att 5_Participant Eligiility Form	0920-	Project NICE: Navigating Insurance Coverage Expansion - Participant Eligibility Form
Att 7_Participant Enrollment Form	0920	Participant Enrollment Form
Att 6_Informed Consent Form	0920-	Informed Consent Form

---

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	3,500	0	0	3,500	0	0
Annual Time Burden (Hours)	875	0	0	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: This is a NEW collection request for a new OMB control Number.

---

Annual Cost to Federal Government: $565,880

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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]? Yes

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 06/27/2018

---