OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being

ICR 201607-0920-007 · OMB 0920-1122 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Contact information - Spanish Form Unchanged Available
Contact information - English Form Unchanged Available
Survey questionnaire Form Modified Available
Non-Sub Change Request_CH STRONG.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-07-20 Available
Att. 11 - References.pdf Supplementary Document Uploaded 2016-07-01 Available
Att. 13 - Spanish Intro.pdf Supplementary Document Uploaded 2016-07-01 Available
Att. 7 - Intro Letter.pdf Supplementary Document Uploaded 2016-07-01 Available
Att. 16 - Spanish Letter to Mother.pdf Supplementary Document Uploaded 2016-07-01 Available
Att. 15 - Letter to Mother.pdf Supplementary Document Uploaded 2016-07-01 Available
Att. 14 - Spanish Consent.pdf Supplementary Document Uploaded 2016-07-01 Available
Att. 5 - Consent.pdf Supplementary Document Uploaded 2016-07-01 Available
CH STRONG_Supporting Statement Part A_20160609_clean.docx Supporting Statement A Uploaded 2016-07-01 Available
Att. 16 - Spanish Letter to Mother.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 15 - Letter to Mother.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 13 - Spanish Consent.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 12 - Spanish Intro.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 10 - References.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 9 - Reminder Phone Call Script.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 8 - Postcards.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 7 - Intro Letter.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 6 - Consent.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 5 - IRB Approval Letter.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 4 - External Reviewers.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 2 - 60-Day FRN.pdf Supplementary Document Uploaded 2016-02-04 Available
Att. 1 - Authorizing Legislation.pdf Supplementary Document Uploaded 2016-02-04 Available
CH STRONG_Supporting Statement Part B_20160609_clean.docx Supporting Statement B Uploaded 2016-07-01 Available
IC Document Collections
IC IDCollectionTypeStatusForm
220012 Contact information - Spanish Form Unchanged
220011 Contact information - English Form Unchanged
220010 Survey questionnaire Form Modified
ICR Details
0920-1122 201607-0920-007
Historical Active 201601-0920-013
HHS/CDC 15BHD
Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 07/21/2016
Retrieve Notice of Action (NOA) 07/21/2016
Approved consistent with the understanding that incentives will be provided as follows: $5 prepaid incentive sent with the survey, and a $10 incentive contingent upon completion of the survey.
  Inventory as of this Action Requested Previously Approved
07/31/2017 07/31/2017 07/31/2017
7,565 0 7,565
2,254 0 2,254
0 0 0
This is a request to add one question to the survey instrument, in English and Spanish, without a change in burden. The purpose of this survey is to collect information on barriers to health care, quality of life, social and educational outcomes, and transition of care from childhood to adulthood among adults born with congenital heart defects.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  80 FR 195 10/08/2015
81 FR 7344 02/11/2016
No
  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 7,565 7,565 0 0 0 0
Annual Time Burden (Hours) 2,254 2,254 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$882,000
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Shari Steinberg 404 639-4942 [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.
07/21/2016