Well-Integrated Screening and Evaluation for Women Across the Nation(WISEWOMAN) Reporting System

Forms and Documents

Document Name	Status
Progress Report Form	Modified
0920-0612 SS Part B 10 26 2012.doc Supporting Statement B	2012-12-12
Attachment 8 Consent Guidance 09 30 2012.doc Supplementary Document	2012-12-12
Attachment 7 WISEWOMAN Map.docx Supplementary Document	2012-12-12
Attachment 6 Contact Info for WISEWOMAN Programs 09 30 2012.docx Supplementary Document	2012-12-12
Attachment 2b Summary of Public Comments.docx Supplementary Document	2012-12-12
Attachment 2a Federal Register Notice.pdf Supplementary Document	2012-12-12
Attachment 1b 301PHSA.pdf Supplementary Document	2012-12-12
Attachment 1a PL 101.pdf Supplementary Document	2012-12-12
Attachment 4b Screen Shots of Portal.docx Supplementary Document	2012-12-12
Attachment 3b Screen Shots of Portal.docx Supplementary Document	2012-12-12
0920-0612 SS Part A 10 26 2012.doc Supporting Statement A	2012-12-12

IC Document Collections

IC ID	Document Title	Status
37802	Screening and Assessment Minimum Data Elements (MDEs) Instruction	Modified
191867	Progress Report Form	Modified
191866	Lifestyle Intervention Minimum Data Elements (MDEs) Instruction	Modified

ICR Details

OMB Control No: 0920-0612	ICR Reference No: 201301-0920-004
Status: Historical Active	Previous ICR Reference No: 201101-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Well-Integrated Screening and Evaluation for Women Across the Nation(WISEWOMAN) Reporting System
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/31/2013
	Date Received in OIRA: 01/04/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2014	12 Months From Approved	03/31/2013
Responses	126	0	126
Time Burden (Hours)	1,680	0	1,680
Cost Burden (Dollars)	0	0	0

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Abstract: CDC requests a one year extension to collect information from WISEWOMAN grantees about activities to be conducted in the final year of the current cooperative agreement. The information collection consists of grantees progress reports and minumum data elements that describe the screening, assessment, and lifestyle intervention services provided to women through the WISEWOMAN program.

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Authorizing Statute(s): PL: Pub.L. 101 - 354 300n-4a Name of Law: The Breast and Cervical Cancer Mortality Prevention Act of 1990
   US Code: 42 USC 301 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:
	77 FR 62515	10/15/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 76044	12/26/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Screening and Assessment Minimum Data Elements (MDEs)
Lifestyle Intervention Minimum Data Elements (MDEs)
Progress Report	none	Progress Report

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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	126	126	0	0	0	0
Annual Time Burden (Hours)	1,680	1,680	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $356,789

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? Yes

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: 01/04/2013

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