CTEP Support Contracts Forms and Surveys (NCI)

Forms and Documents

Document Name	Status
Form 77 ETCTN RS Survey (Attachment C13) Form	New
Form 76 ETCTN PI Survey (Attachment C12) Form	New
Form 75 Low Accural clinical Trial Survey (Attachment C11) Form	New
Form 74 Prospective Clinical Trial Survey (Attachment C10) Form	New
Form 73 Concept Clinical Trial Survey (Attachment C9) Form	New
Form 72 PIO Customer Satisfaction Survey (Attachment C8) Form	New
Form 71 CIRB Board member Annual Assessment Survey (Attachment C7) Form	New
Form 67 Website Focus Groups, Communication Project (Attachments C6 A-D) Form	New
Form 66 Follow-up survey (Communication Audit) (Attachment C5) Form	New
Form 65 CIRB Customer Satisfaction survey (Attachment C4) Form	New
Form 64 CTSU OPEN Survey (Attachment C3) Form	New
Form 63 CTSU Help Desk Customer Satisfaction Survey (Attachment C2) Form and Instruction	New
Form 62 CTSU Website Customer Satisfaction Survey (Attachment C1) Form	New
Form 61 Change of SI PI Form (Attachment B45) Form and Instruction	New
Form 60 UP or SCN Reporting Form (Attachment B44) Form and Instruction	New
Form 59 Study Closure or Transfer of Study Review Responsibility Form (Attachment B43) Form and Instruction	New
Form 58 Study-Specific worksheet About Local Context (Attachment B42) Form and Instruction	New
Form 57 Annual Principal Investigator Worksheet About Local Context (Attachment B41) Form and Instruction	New
Form 56 Annual signatory Institution Worksheet About Local Context (Attachment B40) Form and Instruction	New
Form 55 Reviewer Worksheet CPC - Determination of UP or SCN (Attachment B39) Form and Instruction	New
Form 54 Reviewer Worksheet of Expedited IR (Attachment B38) Form and Instruction	New
Form 53 Reviewer Worksheet expedited Review of Study Chair Response to CIRB-Required Modifications (Attachment B37) Form and Instruction	New
Form 52 Reviewer worksheet Expedited Study Closure Review (Attachment B36) Form and Instruction	New
Form 51 Reviewer Worksheet of Recruitment Material (Attachment B35) Form and Instruction	New
Form 50 Reviewer Worksheet of Translated Documents (Attachment B34) Form and Instruction	New
Form 49 CIRB Application for Translated Documents (Attachment B33) Form and Instruction	New
Form 48 Reviewer worksheet CIRB Statistical Reviewer Form (Attachment B32) Form and Instruction	New
Form 47 Reviewer Worksheet Determination of UP or SCN (Attachment B31) Form and Instruction	New
Form 46 Pediatric Expedited Strudy Chair Response to Required Mod (Attachment B30) Form and Instruction	New
Form 45 Adult Expedited Study Chair Response to Required Mod (Attachment B29) Form and Instruction	New
Form 44 Pediatric Cooperative Group Response to CIRB Review (Attachment B28) Form and Instruction	New
Form 43 Adult Cooperative Group Response to CIRB Review (Attachment B27) Form and Instruction	New
Form 42 Pediatric Expedited Continuing Review (Attachment B26) Form and Instruction	New
Form 41 Adult Expedited Continuing Review (Attachment B25) Form and Instruction	New
Form 40 Pediatric Expedited Amendment Review (Attachment B24) Form and Instruction	New
Form 39 Adult Expedited Amendment Review (Attachment B23) Form and Instruction	New
Form 38 CPC Pharmacist's Review of Cooperative Group Study (Attachment B22) Form and Instruction	New
Form 37 Pharmacist's Review of a Cooperative Group Study (Attachment B21) Form and Instruction	New
Form 36 Pediatric Amendment of Cooperative Group Protocol (Attachment B20) Form and Instruction	New
Form 35 Adult amendment of Cooperative Group Protocol (Attachment B19) Form and Instruction	New
Form 34 Pediatric Continuing Review of Cooperative Group Protocol (Attachment B18) Form and Instruction	New
Form 33 Adult Continuing Review of Cooperative Group Protocol (Attachment B17) Form and Instruction	New
Form 32 Pediatric IR of Cooperative Group Protocol (Attachment B16) Form and Instruction	New
Form 31 Adult IR of cooperative Group Protocol (Attachment B15) Form and Instruction	New
Form 30 CIRB Continuing Review Application (Attachment B14) Form and Instruction	New
Form 29 CIRB Ancillary Studies Application (Attachment B13) Form and Instruction	New
Form 28 CIRB Amendment Review Application (Attachment B12) Form and Instruction	New
Form 27 CIRB IR Application for Exempt Studies (Attachment B11) Form and Instruction	New
Form 26 CIRB IR Application (Attachment B10) Form and Instruction	New
Form 25 CIRB COI Screening for CIRB meetings (Attachment B9) Form and Instruction	New
Form 24 CIRB Member COI Screening Worksheet (Attachment B8) Form and Instruction	New
Form 23 CIRB Direct Deposit Form (Attachment B7) Form	New
Form 22 CIRB Board Member NDA (Attachment B6) Form and Instruction	New
Form 21 CIRB Board member Contact Information Form (Attachment B4) Form and Instruction	New
Form 20 CIRB Board member Biographical Sketch (Attachment B3) Form and Instruction	New
Form 19 NCI CIRB Signatory Enrollment Form (Attachment B2) Form and Instruction	New
Form 18 NCI CIRB AA & DOR between the NCI CIRB and Signatory Institution (Attachment B1) Form and Instruction	New
Form 17 CTSU System Access Request Form (Attachment A17) Form and Instruction	New
Form 16 CTSU Transfer Form (Attachment A16) Form and Instruction	New
Form 15 CTSU Patient Enrollment Transmittal Form (Attachment A15) Form and Instruction	New
Form 14 Uncolicited Data Modification Form: Protocol: TAILORx/PACCT-1 (Attachment A14) Form and Instruction	New
Form 13 TAILORx_PACCT1_Data Transmittal Form (Attachment A13) Form and Instruction	New
Form 12 CTSU Generic Data transmittal form (Attachment A12) Form and Instruction	New
Form 11 MC0845 (8233) CTSU Data Transmittal Form (Attachment A11) Form and Instruction	New
Form 10 RTOG 0834 CTSU Data Transmittal Form (Attachment A10) Form and Instruction	New
Form 9 Data Clarification Form (Attachment A9) Form and Instruction	New
Form 8 Site Initated Data Update Form (Attachment A8) Form and Instruction	New
Form 7 CTSU Supply Request Form (Attachment A7) Form and Instruction	New
Form 6 CTSU Request for Clinical Brochure (Attachment A6) Form and Instruction	New
Form 5 CTSU Roster Update Form (Attachment A5) Form and Instruction	New
Form 4 Site Addition Form (Attachment A4) Form and Instruction	New
Form 3 Withdrawl from Protocol Participation Form (Attachment A3) Form and Instruction	New
Form 2 CTSU IRB Certification Form (Attachment A2) Form and Instruction	New
Form 1 CTSU IRB/Regulatory Approval Transmittal Form (Attachment A1) Form and Instruction	New
30dayFRN2017-04253.pdf Supplementary Document	2017-03-07
attachment_D07 - CIRB - Privacy Act Memo_10_2009.pdf Supplementary Document	2017-03-03
attachment_D06 - CIRB - Emmes IRB_exempt_09_2016.pdf Supplementary Document	2017-03-03
attachment_D05 - CIRB - OHSR Determination.pdf Supplementary Document	2017-03-03
attachment_D04 - CIRB_FIPS_199_09_2015.pdf Supplementary Document	2017-03-03
attachment_D03_privacy act memo.pdf Supplementary Document	2017-03-03
attachment_D02_irb and OHSR determination.pdf Supplementary Document	2017-03-03
attachment_D01_CTSU_PIA.pdf Supplementary Document	2017-03-03
SSA CTEP Support Contracts Forms and Surveys_Final.docx Supporting Statement A	2017-05-31
SSB CTEP.docx Supporting Statement B	2017-02-28

IC Document Collections

IC ID	Document Title	Status
225931	ETCTN RS Survey (Attachment C13) Form	New
225930	ETCTN PI Survey (Attachment C12) Form	New
225929	Low Accural clinical Trial Survey (Attachment C11) Form	New
225928	Prospective Clinical Trial Survey (Attachment C10) Form	New
225927	Concept Clinical Trial Survey (Attachment C9) Form	New
225926	PIO Customer Satisfaction Survey (Attachment C8) Form	New
225925	CIRB Board member Annual Assessment Survey (Attachment C7) Form	New
225924	Website Focus Groups, Communication Project (Attachments C6 A-D) Form	New
225923	Follow-up survey (Communication Audit) (Attachment C5) Form	New
225922	CIRB Customer Satisfaction survey (Attachment C4) Form	New
225921	CTSU OPEN Survey (Attachment C3) Form	New
225919	CTSU Help Desk Customer Satisfaction Survey (Attachment C2) Form and Instruction	New
225918	CTSU Website Customer Satisfaction Survey (Attachment C1) Form	New
225917	Change of SI PI Form (Attachment B45) Form and Instruction	New
225916	UP or SCN Reporting Form (Attachment B44) Form and Instruction	New
225915	Study Closure or Transfer of Study Review Responsibility Form (Attachment B43) Form and Instruction	New
225914	Study-Specific worksheet About Local Context (Attachment B42) Form and Instruction	New
225913	Annual Principal Investigator Worksheet About Local Context (Attachment B41) Form and Instruction	New
225912	Annual signatory Institution Worksheet About Local Context (Attachment B40) Form and Instruction	New
225911	Reviewer Worksheet CPC - Determination of UP or SCN (Attachment B39) Form and Instruction	New
225910	Reviewer Worksheet of Expedited IR (Attachment B38) Form and Instruction	New
225909	Reviewer Worksheet expedited Review of Study Chair Response to CIRB-Required Modifications (Attachment B37) Form and Instruction	New
225908	Reviewer worksheet Expedited Study Closure Review (Attachment B36) Form and Instruction	New
225907	Reviewer Worksheet of Recruitment Material (Attachment B35) Form and Instruction	New
225906	Reviewer Worksheet of Translated Documents (Attachment B34) Form and Instruction	New
225904	CIRB Application for Translated Documents (Attachment B33) Form and Instruction	New
225903	Reviewer worksheet CIRB Statistical Reviewer Form (Attachment B32) Form and Instruction	New
225902	Reviewer Worksheet Determination of UP or SCN (Attachment B31) Form and Instruction	New
225901	Pediatric Expedited Strudy Chair Response to Required Mod (Attachment B30) Form and Instruction	New
225900	Adult Expedited Study Chair Response to Required Mod (Attachment B29) Form and Instruction	New
225899	Pediatric Cooperative Group Response to CIRB Review (Attachment B28) Form and Instruction	New
225898	Adult Cooperative Group Response to CIRB Review (Attachment B27) Form and Instruction	New
225897	Pediatric Expedited Continuing Review (Attachment B26) Form and Instruction	New
225895	Adult Expedited Continuing Review (Attachment B25) Form and Instruction	New
225894	Pediatric Expedited Amendment Review (Attachment B24) Form and Instruction	New
225893	Adult Expedited Amendment Review (Attachment B23) Form and Instruction	New
225892	CPC Pharmacist's Review of Cooperative Group Study (Attachment B22) Form and Instruction	New
225891	Pharmacist's Review of a Cooperative Group Study (Attachment B21) Form and Instruction	New
225890	Pediatric Amendment of Cooperative Group Protocol (Attachment B20) Form and Instruction	New
225889	Adult amendment of Cooperative Group Protocol (Attachment B19) Form and Instruction	New
225888	Pediatric Continuing Review of Cooperative Group Protocol (Attachment B18) Form and Instruction	New
225887	Adult Continuing Review of Cooperative Group Protocol (Attachment B17) Form and Instruction	New
225886	Pediatric IR of Cooperative Group Protocol (Attachment B16) Form and Instruction	New
225885	Adult IR of cooperative Group Protocol (Attachment B15) Form and Instruction	New
225884	CIRB Continuing Review Application (Attachment B14) Form and Instruction	New
225883	CIRB Ancillary Studies Application (Attachment B13) Form and Instruction	New
225882	CIRB Amendment Review Application (Attachment B12) Form and Instruction	New
225881	CIRB IR Application for Exempt Studies (Attachment B11) Form and Instruction	New
225880	CIRB IR Application (Attachment B10) Form and Instruction	New
225879	CIRB COI Screening for CIRB meetings (Attachment B9) Form and Instruction	New
225878	CIRB Member COI Screening Worksheet (Attachment B8) Form and Instruction	New
225877	CIRB Direct Deposit Form (Attachment B7) Form	New
225876	CIRB Board Member NDA (Attachment B6) Form and Instruction	New
225875	CIRB Board member Contact Information Form (Attachment B4) Form and Instruction	New
225874	CIRB Board member Biographical Sketch (Attachment B3) Form and Instruction	New
225873	NCI CIRB Signatory Enrollment Form (Attachment B2) Form and Instruction	New
225871	NCI CIRB AA & DOR between the NCI CIRB and Signatory Institution (Attachment B1) Form and Instruction	New
225870	CTSU System Access Request Form (Attachment A17) Form and Instruction	New
225868	CTSU Transfer Form (Attachment A16) Form and Instruction	New
225866	CTSU Patient Enrollment Transmittal Form (Attachment A15) Form and Instruction	New
225863	Uncolicited Data Modification Form: Protocol: TAILORx/PACCT-1 (Attachment A14) Form and Instruction	New
225862	TAILORx_PACCT1_Data Transmittal Form (Attachment A13) Form and Instruction	New
225861	CTSU Generic Data transmittal form (Attachment A12) Form and Instruction	New
225860	MC0845 (8233) CTSU Data Transmittal Form (Attachment A11) Form and Instruction	New
225857	RTOG 0834 CTSU Data Transmittal Form (Attachment A10) Form and Instruction	New
225853	Data Clarification Form (Attachment A9) Form and Instruction	New
225852	Site Initated Data Update Form (Attachment A8) Form and Instruction	New
225850	CTSU Supply Request Form (Attachment A7) Form and Instruction	New
225847	CTSU Request for Clinical Brochure (Attachment A6) Form and Instruction	New
225846	CTSU Roster Update Form (Attachment A5) Form and Instruction	New
225845	Site Addition Form (Attachment A4) Form and Instruction	New
225844	Withdrawl from Protocol Participation Form (Attachment A3) Form and Instruction	New
225843	CTSU IRB Certification Form (Attachment A2) Form and Instruction	New
225841	CTSU IRB/Regulatory Approval Transmittal Form (Attachment A1) Form and Instruction	New

ICR Details

OMB Control No: 0925-0753	ICR Reference No: 201702-0925-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: CTEP Support Contracts Forms and Surveys (NCI)
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: 06/01/2017
	Date Received in OIRA: 03/07/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved
Responses	100,337	0	0
Time Burden (Hours)	15,524	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This is a new information collection seeking approval for three years. The National Cancer Institute (NCI) Cancer Therapy Evaluation Program (CTEP) and the Division of Cancer Prevention (DCP) fund an extensive national program of cancer research, sponsoring clinical trials in cancer prevention, symptom management and treatment for qualified clinical investigators. As part of this effort, CTEP and DCP oversee two support programs, the NCI Central Institutional Review Board (CIRB) and the Cancer Trial Support Unit (CTSU). The information collected for both programs is for the purposes of membership, enrollment, opening of Institutional Review Board (IRB) approved studies, documenting IRB review, regulatory approval (for sites not using the CIRB), patient enrollment, and routing of case report forms. Information will also be collected through surveys to assess satisfaction and provide feedback to guide improvements with processes and technology as well as assessing health professional’s interests in clinical trials.

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Authorizing Statute(s): US Code: 42 USC 285a 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:
	81 FR 89955	12/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12618	03/06/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 74

IC Title	Form No.	Form Name
MC0845 (8233) CTSU Data Transmittal Form (Attachment A11)	11	8233 Form
CTSU Transfer Form (Attachment A16)	16	Transfer
NCI CIRB Signatory Enrollment Form (Attachment B2)	19	NCI CIRB Signatory Enrollment Form
CIRB Board Member NDA (Attachment B6)	22	CIRB Member NDA
CIRB Member COI Screening Worksheet (Attachment B8)	24	COI Screen
CIRB COI Screening for CIRB meetings (Attachment B9)	25	COI Screening
CIRB Ancillary Studies Application (Attachment B13)	29	CIRB Ancillary Application
Adult IR of cooperative Group Protocol (Attachment B15)	31	Adult IR FB Reviewer Worksheet
Adult Continuing Review of Cooperative Group Protocol (Attachment B17)	33	Adult CR FB Reviewer Worksheet
Pediatric Continuing Review of Cooperative Group Protocol (Attachment B18)	34	Oed CR FB Reviewer Worksheet
Adult Expedited Amendment Review (Attachment B23)	39	Adult & CPC Expedited Reviewer Worksheet
Pediatric Expedited Continuing Review (Attachment B26)	42	Ped Expedited CR Worksheet
Pediatric Cooperative Group Response to CIRB Review (Attachment B28)	44	Ped FB SCRWksht
Reviewer worksheet CIRB Statistical Reviewer Form (Attachment B32)	48	reviewer Worksheet CIRB Stat
CIRB Application for Translated Documents (Attachment B33)	49	CIRB App for Translated Docs
Reviewer Worksheet CPC - Determination of UP or SCN (Attachment B39)	55	Reviewer Worksheet CPC UP FB
Website Focus Groups, Communication Project (Attachments C6 A-D)	69, 70, 67, 68	CIRB Website Focus Group Survey - CIRB Members usability ,   CIRB Website Focus Group Survey - Local Instiutions usability ,   CIRB Website Focus Group Survey - Network Groups usability ,   CIRB Website Focus Group Survey -Web site usability testing
PIO Customer Satisfaction Survey (Attachment C8)	72	PIO External Survey
Low Accural clinical Trial Survey (Attachment C11)	75	low accuring survey
CIRB Amendment Review Application (Attachment B12)	28	CIRB AR Application
Pediatric IR of Cooperative Group Protocol (Attachment B16)	32	Ped IR FB Reviewerworksheet
Adult amendment of Cooperative Group Protocol (Attachment B19)	35	Adult AR FB Reviewer Worksheet
Pediatric Expedited Strudy Chair Response to Required Mod (Attachment B30)	46	Ped Exped Chair Resp Req Mods
Reviewer worksheet Expedited Study Closure Review (Attachment B36)	52	reviewer Worksheet ER ClosureWksht
Reviewer Worksheet of Expedited IR (Attachment B38)	54	Reviewer Worksheet ER IR
CTSU Help Desk Customer Satisfaction Survey (Attachment C2)	63	Help Desk Survey
Follow-up survey (Communication Audit) (Attachment C5)	66	CIRB FUP Survey
ETCTN PI Survey (Attachment C12)	76	ETCTN PI Survey
Reviewer Worksheet of Translated Documents (Attachment B34)	50	Reviewer Worksheet Translated Docs
Study-Specific worksheet About Local Context (Attachment B42)	58	SSW Worksheet
TAILORx_PACCT1_Data Transmittal Form (Attachment A13)	13	TAILORx PACCT1_DTF
CTSU Generic Data transmittal form (Attachment A12)	12	Generic Data
CTSU System Access Request Form (Attachment A17)	17	System Access Request form
CIRB IR Application (Attachment B10)	26	CIRB IR Application
CPC Pharmacist's Review of Cooperative Group Study (Attachment B22)	38	CPC FB Pharma Reviewer Worksheet
Adult Expedited Continuing Review (Attachment B25)	41	Adult & CPC Expedited CR Worksheet
Annual signatory Institution Worksheet About Local Context (Attachment B40)	56	Annual SI Worksheet
CTSU OPEN Survey (Attachment C3)	64	OPEN survey
CIRB Board member Annual Assessment Survey (Attachment C7)	71	Annual CIRB Board Assessment
Prospective Clinical Trial Survey (Attachment C10)	74	Prospective Survey
Uncolicited Data Modification Form: Protocol: TAILORx/PACCT-1 (Attachment A14)	14	TAILORx UDM
CIRB IR Application for Exempt Studies (Attachment B11)	27	CIRB IR Exempt Application
CIRB Continuing Review Application (Attachment B14)	30	CIRB CR Application
Pediatric Amendment of Cooperative Group Protocol (Attachment B20)	36	Ped AR FB Reviewer Worksheet
Pharmacist's Review of a Cooperative Group Study (Attachment B21)	37	Adult Ped FB Pharma Adult Reviewer Worksheet
Reviewer Worksheet Determination of UP or SCN (Attachment B31)	47	Reviewer Worksheet UP FB
Reviewer Worksheet of Recruitment Material (Attachment B35)	51	Reviewer Worksheet Recruitment materials
Reviewer Worksheet expedited Review of Study Chair Response to CIRB-Required Modifications (Attachment B37)	53	Reviewer Worksheet SCR ER
Annual Principal Investigator Worksheet About Local Context (Attachment B41)	57	Annual PI Worksheet
UP or SCN Reporting Form (Attachment B44)	60	Unanticipated Problem Worksheet
Change of SI PI Form (Attachment B45)	61	Change PI Worksheet
CTSU Website Customer Satisfaction Survey (Attachment C1)	62	websurvey final
CIRB Customer Satisfaction survey (Attachment C4)	65	CIRB Satisfaction survey
Concept Clinical Trial Survey (Attachment C9)	73	Concept Survey
Data Clarification Form (Attachment A9)	9	Data Clarification Form
CIRB Direct Deposit Form (Attachment B7)	23	CIRB Direct Deposit Form
Pediatric Expedited Amendment Review (Attachment B24)	40	Ped Expedited Reviewer Worksheet
Study Closure or Transfer of Study Review Responsibility Form (Attachment B43)	59	Study Closure Worksheet
ETCTN RS Survey (Attachment C13)	77	ETCTN
CTSU IRB Certification Form (Attachment A2)	2	IRB Certification
Site Addition Form (Attachment A4)	4	Site Addition
CTSU IRB/Regulatory Approval Transmittal Form (Attachment A1)	1	IRB Transmittal
Withdrawl from Protocol Participation Form (Attachment A3)	3	Withdrawl form
Site Initated Data Update Form (Attachment A8)	8	Site Data Update form
NCI CIRB AA & DOR between the NCI CIRB and Signatory Institution (Attachment B1)	18	NCI CIRB AA DivofResps
CIRB Board member Biographical Sketch (Attachment B3)	20	CIRB Biosketch Questions CIRB member
CIRB Board member Contact Information Form (Attachment B4)	21	CIRB ContactInfoForm
Adult Cooperative Group Response to CIRB Review (Attachment B27)	43	Adult & CPC FB SCRWksht
Adult Expedited Study Chair Response to Required Mod (Attachment B29)	45	Adult & CPC Exped Chair Resp Req Mods
RTOG 0834 CTSU Data Transmittal Form (Attachment A10)	10	RTOG0834
CTSU Patient Enrollment Transmittal Form (Attachment A15)	15	Patient Enrollment Transmittal form
CTSU Roster Update Form (Attachment A5)	5	Roster Update
CTSU Request for Clinical Brochure (Attachment A6)	6	Clinical Brochure
CTSU Supply Request Form (Attachment A7)	7	Supply

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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	100,337	0	0	100,337	0	0
Annual Time Burden (Hours)	15,524	0	0	15,524	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: New submission

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Annual Cost to Federal Government: $689,035

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: 03/07/2017

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