Evaluation of the Chronic Disease Self-Management Program in the US Affiliated Pacific Islands

Forms and Documents

Document Name	Status
Chronic Disease Self-management Questionnaire Form	New
Chronic Disease Self-management Workshop Evaluation Form	New
Att. 8 Privacy Impact Assesment.pdf Supplementary Document	2019-01-31
Att. 7_Institutional Review Board Approval Notification or exemption determination.pdf Supplementary Document	2019-01-31
Att. 6 Participants in Consultation Outside the Agency.docx Supplementary Document	2019-01-31
Att. 5 CDSMP Evaluation Consent Form.docx Supplementary Document	2019-01-31
Att. 3_Data Collection and Data Flow Process.docx Supplementary Document	2019-01-31
Att. 2 60 Day Federal Register Notice.pdf Supplementary Document	2019-01-31
Att. 1 Authorizing Legislation Section 301(a) of the Public Health Service Act [42.U.S.C. 242K].pdf Supplementary Document	2019-01-31
Supporting Statement -Part B 326.docx Supporting Statement B	2019-06-03
Supporting Statement-Part A 326.docx Supporting Statement A	2019-06-03

IC Document Collections

IC ID	Document Title	Status
234803	Chronic Disease Self-management Questionnaire Form	New
234802	Chronic Disease Self-management Workshop Evaluation Form	New

ICR Details

OMB Control No: 0920-1265	ICR Reference No: 201901-0920-012
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-18FJ
Title: Evaluation of the Chronic Disease Self-Management Program in the US Affiliated Pacific Islands
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: 06/05/2019
	Date Received in OIRA: 02/15/2019
Terms of Clearance: Approved consistent with the understanding that CDC will not be conducting any general research on the information collected. When communicating findings from this collection, all publications will clearly describe the scope and limitations of the study findings.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	24 Months From Approved
Responses	570	0	0
Time Burden (Hours)	95	0	0
Cost Burden (Dollars)	570	0	0

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Abstract: This collection is to evaluate the first implementation of Stanford University's Chronic Disease Self-Management Program in the US Affiliated Pacific Islands. The evaluation will assess program participation satisfaction with the program and participants' overall health and health behaviors before and after the program.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service 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:
	83 FR 4917	02/02/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 4469	02/15/2019
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
Chronic Disease Self-management Workshop Evaluation	none	Workshop Evaluation
Chronic Disease Self-management Questionnaire	none	Workshop Questionnaire

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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	570	0	0	570	0	0
Annual Time Burden (Hours)	95	0	0	95	0	0
Annual Cost Burden (Dollars)	570	0	0	570	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 ICR

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Annual Cost to Federal Government: $19,501

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.     No

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]? 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: 02/15/2019

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