OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

WISEWOMAN National Program Evaluation: Implementation Assessment

ICR 201412-0920-005 · OMB 0920-1068 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Private Sector Form New Available
(Private Sector) Awardee Partners Discussion Guide Form New Available
(Private Sector) Awardee Partners Network Survey Form New Available
Clinical Providers Form New Available
Healthy Behavior Support Staff Site Visit Discussion Guide Form New Available
Awardee Partners Site Visit Discussion Guide Form New Available
Awardee Partners Network Survey Form New Available
Awardee Administrators Site Visit Discussion Guide Form New Repair queued
Awardee Administrators Network Survey Form New Repair queued
Awardee Administrators Program Survey Form New Available
Attachment B proposed outcomes and measures_5 27 2015.docx Supplementary Document Uploaded 2015-05-27 Available
Attachment B proposed outcomes and measures.docx Supplementary Document Uploaded 2014-12-04 Available
Attachment E5 Consent form.docx Supplementary Document Uploaded 2014-12-04 Available
IRB exempt.pdf Supplementary Document Uploaded 2014-12-04 Available
Attachment F2 Summary of Public Comments.docx Supplementary Document Uploaded 2014-12-04 Available
Attachment F1 Federal Register Notice.pdf Supplementary Document Uploaded 2014-12-04 Available
Attachment A1 A2 authorizing legislation.pdf Supplementary Document Uploaded 2014-12-04 Available
WISEWOMAN OMB Part B_11 07 2014.docx Supporting Statement B Uploaded 2014-12-04 Available
WISEWOMAN OMB Part A_5 27 2015.docx Supporting Statement A Uploaded 2015-05-27 Available
IC Document Collections
IC IDCollectionTypeStatusForm
214159 Private Sector Form New
214158 (Private Sector) Awardee Partners Discussion Guide Form New
214157 (Private Sector) Awardee Partners Network Survey Form New
214155 Clinical Providers Form New
214154 Healthy Behavior Support Staff Site Visit Discussion Guide Form New
214153 Awardee Partners Site Visit Discussion Guide Form New
214152 Awardee Partners Network Survey Form New
214151 Awardee Administrators Site Visit Discussion Guide Form New
214150 Awardee Administrators Network Survey Form New
214149 Awardee Administrators Program Survey Form New
ICR Details
0920-1068 201412-0920-005
Historical Active
HHS/CDC 414AUI
WISEWOMAN National Program Evaluation: Implementation Assessment
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 05/29/2015
Retrieve Notice of Action (NOA) 12/22/2014
  Inventory as of this Action Requested Previously Approved
05/31/2018 36 Months From Approved
219 0 0
132 0 0
0 0 0
Approval is requested for 3 years to conduct a program implementation assessment of the WISEWOMAN program (Well-Integrated Screening and Evaluation for Women Across the Nation). The proposed new information collection will gather process data to improve understanding of how WISEWOMAN awardees implement program activities. The information collection includes a program survey, a network survey, and site visits.
US Code: 42 USC 241 Name of Law: Public Health Service Act
   PL: Pub.L. 101 - 354 300k Name of Law: Breast and Cervical Cancer Mortality Prevention Act of 1990
  
None
Not associated with rulemaking
  79 FR 50653 08/25/2014
79 FR 74097 12/15/2014
Yes
  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 219 0 0 219 0 0
Annual Time Burden (Hours) 132 0 0 132 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new data collection request.
$150,000
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Carol Marsh 404 639-4773 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
12/22/2014