Oral Health Basic Screening Survey for Children

Forms and Documents

Document Name	Status
Form 0920-20PM Oral Health Basic Screening Survey for Children Form and Instruction	New
Form 0920-20PM School Participation Form Form and Instruction	New
Form 0920-20PM Child Screening Form Form and Instruction	New
Form 0920-20PM Consent Form Form and Instruction	New
Form 0920-20PM Screener Screening Form Form and Instruction	New
privacy narrative-DOH Basic Screening Survey 12-07-2020 rks cla.pdf Supplementary Document	2021-02-01
5_ASTDD sample screening budget.pdf Supplementary Document	2021-02-01
4_IRB exemption.pdf Supplementary Document	2021-02-01
3b_60day FRN_BSS_comments and response_10222020.docx Supplementary Document	2021-02-01
2h_request and reminder email to states for data_03122020_clean.docx Supplementary Document	2021-02-01
2g_notice of screening results.docx Supplementary Document	2021-02-01
2d_invitation to schools.docx Supplementary Document	2021-02-01
2c_guidance on data analysis.pdf Supplementary Document	2021-02-01
2b_guidance on sampling design.pdf Supplementary Document	2021-02-01
1_Legislation.pdf Supplementary Document	2021-02-01
30 Day FRN 012820.pdf Supplementary Document	2021-02-01
60Day FRN 070220.pdf Supplementary Document	2021-02-01
SSB_children BSS_05292020_30Day_111622020_clean.docx Supporting Statement B	2021-02-01
SSA_children BSS_30-Day FRN_0529_11162020_clean.docx Supporting Statement A	2021-02-01

IC Document Collections

IC ID	Document Title	Status
245500	Oral Health Basic Screening Survey for Children Form and Instruction	New
245499	School Participation Form Form and Instruction	New
245498	Child Screening Form Form and Instruction	New
245497	Consent Form Form and Instruction	New
245496	Screener Screening Form Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202102-0920-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-20PM
Title: Oral Health Basic Screening Survey for Children
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  Yes
Type of Review Request: Regular	Date Submitted to OIRA: 02/02/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	303,965	0
Time Burden (Hours)	40,207	0
Cost Burden (Dollars)	0	0

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Abstract: CDC collects state-level prevalence of dental caries and sealants among children from state oral health programs and publishes on CDC's public-facing website to 1) facilitate state oral health surveillance capacity to monitor oral health status, trends, and disparities, and to compare with other states; 2) inform planning and evaluation of oral health programs and policies; 3) measure progress toward the Healthy People objectives; and 4) educate the public and policy makers regarding cross-cutting public health programs. CDC also uses the data to evaluate performance of CDC oral health funding recipients.

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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:
	85 FR 39911	07/02/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 7399	01/28/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Screener Screening Form	0920-20PM	Screening Form
Consent Form	0920-20PM	Consent Form
Child Screening Form	0920-20PM	Screening FORM
School Participation Form	0920-20PM	School Participation Form
Oral Health Basic Screening Survey for Children	0920-20PM	Data Submission form

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ICR Summary of Burden

	Total Request	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	303,965	0	0	303,965	0	0
Annual Time Burden (Hours)	40,207	0	0	40,207	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: The purpose of this data collection is assist states in monitoring the oral health status of children and evaluating public health programs and policies.CDC is requesting approval for 40,207 burden hours.

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Annual Cost to Federal Government: $43,233

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? No

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Common Form ICR:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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: 02/02/2021

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