Performance Measurement and Program Monitoring (Autism and Developmental Disabilities Monitoring (ADDM) Network

Forms and Documents

Document Name	Status
Component A & B (Subsequent 6-month and 2-year submission) - Performance Measures Form and Instruction	New
Component A & B (Subsequent 6-month and 2-year submission) - WORKSHEETS Form and Instruction	New
Component A & B (Subsequent 6-month and 2-year submission) - INTERVIEW Form and Instruction	New
Component A ONLY (Subsequent 6-month and 2-year submission) - PERFORMANCE MEASURES Form and Instruction	New
Component A ONLY (Subsequent 6-month and 2-year submission) - WORKSHEETS Form and Instruction	New
Component A ONLY (Subsequent 6-month and 2-year submission) - INTERVIEW Form and Instruction	New
Component A & B (Initial 6 month submission) - PERFORMANCE MEASURES Form and Instruction	New
Component A & B (Initial 6 month submission) - WORKSHEETS Form and Instruction	New
Component A & B (Initial 6 month submission) - INTERVIEW Form and Instruction	New
Component A ONLY (Initial 6 month submission) - PERFORMANCE MEASURES Form and Instruction	New
Component A ONLY (Initial 6 month submission) - WORKSHEETS Form and Instruction	New
Component A ONLY (Initial 6 month submission) - INTERVIEW Form and Instruction	New
Research determination for ADDM 2014 FOA (2013-08-09).doc Supplementary Document	2016-01-07
SS Part A_ADDM PME_OMB_12JUL2016.docx Supporting Statement A	2016-07-12
Attachment 2A_List of Awardees.docx Supplementary Document	2016-01-05
CDC-2015-0023-0001_ADDM 60-Day Published.pdf Supplementary Document	2016-01-05
Attachment 1B_Public Health Service Act.pdf Supplementary Document	2016-01-05
Attachment 1A_Children's Health Act of 2000.pdf Supplementary Document	2016-01-05
SS Part B_ADDM PME_OMB_12JUL2016.docx Supporting Statement B	2016-07-12

IC Document Collections

IC ID	Document Title	Status
219517	Component A & B (Subsequent 6-month and 2-year submission) - Performance Measures Form and Instruction	New
219516	Component A & B (Subsequent 6-month and 2-year submission) - WORKSHEETS Form and Instruction	New
219515	Component A & B (Subsequent 6-month and 2-year submission) - INTERVIEW Form and Instruction	New
219509	Component A ONLY (Subsequent 6-month and 2-year submission) - PERFORMANCE MEASURES Form and Instruction	New
219508	Component A ONLY (Subsequent 6-month and 2-year submission) - WORKSHEETS Form and Instruction	New
219506	Component A ONLY (Subsequent 6-month and 2-year submission) - INTERVIEW Form and Instruction	New
219505	Component A & B (Initial 6 month submission) - PERFORMANCE MEASURES Form and Instruction	New
219504	Component A & B (Initial 6 month submission) - WORKSHEETS Form and Instruction	New
219503	Component A & B (Initial 6 month submission) - INTERVIEW Form and Instruction	New
219502	Component A ONLY (Initial 6 month submission) - PERFORMANCE MEASURES Form and Instruction	New
219501	Component A ONLY (Initial 6 month submission) - WORKSHEETS Form and Instruction	New
219476	Component A ONLY (Initial 6 month submission) - INTERVIEW Form and Instruction	New

ICR Details

OMB Control No: 0920-1124	ICR Reference No: 201601-0920-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15ZT
Title: Performance Measurement and Program Monitoring (Autism and Developmental Disabilities Monitoring (ADDM) Network
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: Approved with change	Conclusion Date: 07/19/2016
	Date Received in OIRA: 01/11/2016
Terms of Clearance: Approved consistent with the understanding that information collected are intended to ensure program implementation and improvement, program outputs and short term outcomes, inform future modifications to the ADDM surveillance methodology, and assess the education/outreach strategies employed by grantees. Outcomes of this information collection are not intended to demonstrate overall impact of the ADDM network--this will be communicated in all publications and reports to Congress.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2019	36 Months From Approved
Responses	198	0	0
Time Burden (Hours)	123	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Performance Measurement and Program Monitoring (Autism and Developmental Disabilities Monitoring (ADDM) Network submission is a New ICR. The goals of this project are to support performance measurement and program evaluation efforts; ensure awardee compliance with cooperative agreement requirements; maximize effectiveness and timeliness of technical assistance to awardees; and to obtain information needed to demonstrate the program's public health impact.

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Authorizing Statute(s): US Code: 42 USC 241(a) Name of Law: Public Health Service Act
   US Code: 42 USC 247(b) Name of Law: Children's Health 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:
	80 FR 22195	04/21/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 91	01/04/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

IC Title	Form No.	Form Name
Component A ONLY (Initial 6 month submission) - INTERVIEW	NA	ADDM Interview Items
Component A & B (Initial 6 month submission) - INTERVIEW	NA	ADDM Interview Items
Component A ONLY (Subsequent 6-month and 2-year submission) - INTERVIEW	NA	ADDM Interview Items
Component A ONLY (Subsequent 6-month and 2-year submission) - WORKSHEETS	NA	Component A&B Template - Worksheets/Performance Measures
Component A ONLY (Subsequent 6-month and 2-year submission) - PERFORMANCE MEASURES	NA	Component A&B Template - Worksheets/Performance Measures
Component A ONLY (Initial 6 month submission) - WORKSHEETS	NA	Component A&B Template - Worksheets/Performance Measures
Component A ONLY (Initial 6 month submission) - PERFORMANCE MEASURES	NA	Component A&B Template - Worksheets/Performance Measures
Component A & B (Initial 6 month submission) - WORKSHEETS	NA	Component A&B Template - Worksheets/Performance Measures
Component A & B (Initial 6 month submission) - PERFORMANCE MEASURES	NA	Component A&B Template - Worksheets/Performance Measures
Component A & B (Subsequent 6-month and 2-year submission) - INTERVIEW	NA	ADDM Interview Items
Component A & B (Subsequent 6-month and 2-year submission) - WORKSHEETS	NA	Component A&B Template - Worksheets/Performance Measures
Component A & B (Subsequent 6-month and 2-year submission) - Performance Measures	NA	Component A&B Template - Worksheets/Performance Measures

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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	198	0	0	198	0	0
Annual Time Burden (Hours)	123	0	0	123	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: Submission of CDC 0920-15ZT is a New ICR.

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Annual Cost to Federal Government: $160,320

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: 01/11/2016

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