CHIPRA_ Children Health Insurance

Forms and Documents

Document Name	Status
0990-CHIP OMB Supporting Statement Part B_8_22_11.docx Supporting Statement B	2011-09-28
0990-CHIP Part A_Attachment J__Contractor Confidentiality Pledge.pdf Supplementary Document	2011-09-28
0990-CHIP Part A_Attachment I1_Focus Group Consent Form for Parents of CHIP Enrollees.pdf Supplementary Document	2011-09-28
0990-CHIP Part A_Attachment I4_Focus Group Consent Form for Parents of Children Covered by Employer-Sponsored Insurance.pdf Supplementary Document	2011-09-28
0990-CHIP Part A_Attachment I3_Focus Group Consent Form for Parents of Eligible but Uninsured.pdf Supplementary Document	2011-09-28
0990-CHIP Part A_Attachment I2_Focus Group Consent Form for Parents of CHIP Disenrollees.pdf Supplementary Document	2011-09-28
0990-CHIP Part A_Attachment K_Site Visit Consent Procedure.pdf Supplementary Document	2011-09-28
0990-CHIP Supporting Statement Part A Final 8_22_11.docx Supporting Statement A	2011-09-27

IC Document Collections

IC ID	Document Title	Status
199536	Parents and Other Family Members of Children Other-focus	New
199535	CHIP and Medicaid Personnel Other-survey	New
199534	Medicaid Enrollees and Disenrolles Other-study	New
199533	CHIP Enrollees and Disenrollees Other-survey	New

ICR Details

OMB Control No: 0990-0384	ICR Reference No: 201109-0990-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: CHIPRA_ Children Health Insurance
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: Improperly submitted	Conclusion Date: 10/12/2011
	Date Received in OIRA: 09/29/2011
Terms of Clearance: This collection must be resubmitted with all relavent attachments included.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: ASPE will use the data collected and analyzed in the CHIPRA 10-State Evaluation to evaluate the CHIP program and its contributions to closing the health care coverage gap for low-income children whose families do not qualify for Medicaid, but cannot afford private coverage for them. Data from the survey, case studies (site visits and focus groups), and other national datasets will be integrated into the analysis.

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Authorizing Statute(s): US Code: 21 USC 4901 Name of Law: State Children Health Insurance Program
  

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:
	76 FR 17128	03/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 59701	09/27/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
CHIP Enrollees and Disenrollees
Medicaid Enrollees and Disenrolles
CHIP and Medicaid Personnel
Parents and Other Family Members of Children

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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: New collction

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Annual Cost to Federal Government: $8,996,001

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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: 09/29/2011

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