Multi-Site Implementation Evaluation of Tribal Home Visiting

Forms and Documents

Document Name	Status
Supplemental Attachment for Non-Substantive 2 27 2019 CLEAN.docx Justification for No Material/Nonsubstantive Change	2019-02-28
ATTACHMENT L. Intro to MUSE Video Script FINAL_1.17.2019.pdf Supplementary Document	2019-02-28
Attachment E - MIECHV Learning Agenda.docx Supplementary Document	2018-12-21
30 Day FRN_MUSE_8.10.18.pdf Supplementary Document	2018-08-10
MUSE OMB Part B PASSBACK 1.17.19 FINAL CLEAN.pdf Supporting Statement B	2019-02-28
MUSE OMB Part A PASSBACK 1.17.19 FINAL CLEAN.pdf Supporting Statement A	2019-02-28
ATTACHMENT J. Program Data Collection Reminders Emails 2.5.2019.pdf Supplementary Document	2019-02-28
ATTACHMENT I. Caregiver Interview Invitation Phone Script FINAL.docx Supplementary Document	2018-08-08
ATTACHMENT H. Staff Interview Invitation Email and Phone Script FINAL.docx Supplementary Document	2018-08-08
ATTACHMENT G. Staff Survey Invitation Email 2.5.2019.pdf Supplementary Document	2019-02-28
ATTACHMENT F. Caregiver Flyer 2.5.2019.pdf Supplementary Document	2019-02-28
ATTACHMENT E. Caregiver Interviewee Selection Guide FINAL.docx Supplementary Document	2018-08-08
ATTACHMENT D. Documentation of Initial IRB Approval and Amendment Approval.pdf Supplementary Document	2019-02-28
ATTACHMENT C. Agreement to Keep Participant Data Private FINAL.doc Supplementary Document	2018-08-08
ATTACHMENT B. 60 Day Federal Register Notice.pdf Supplementary Document	2018-07-27
ATTACHMENT A. Informed Consents 2.27.2019 CLEAN.pdf Supplementary Document	2019-02-28

IC Document Collections

IC ID	Document Title	Status
232432	16. MUSE Administrative Data Elements 7.26.18 CLEAN Other-Data Elements	Modified
232431	15. MUSE Implementation Logs 7.9.18 CLEAN Other-Implementation Logs	Modified
232430	14. MUSE Caregiver Interview Questions 7.9.18 CLEAN Other-Interview Questions	Unchanged
232429	13. MUSE Local Evaluator Interview Questions 7.9.18 Other-Interview Questions	Unchanged
232427	12. MUSE Program Coordinator-Manager and Program Director Interview Questions 7.9.18 Other-Interview Questions	Unchanged
232426	11. MUSE Home Visitor Interview Questions 7.9.18 Other-Interview Questions	Unchanged
232425	10. Program Implementation Survey 7.9.18 CLEAN Other-Survey	Modified
232424	9. MUSE Local Program Evaluator Survey 7.9.18 CLEAN Other-Survey	Modified
232423	8. MUSE Program Director Survey 7.25.18 CLEAN Other-Survey	Modified
232422	7. MUSE Program Coordinator-Manager Survey 7.25.18 CLEAN Other-Survey	Modified
232421	6. MUSE Home Visitor Survey 7.25.18 CLEAN Other-Survey	Modified
232420	5. MUSE Rapid Reflect Home Visitor 7.25.18 CLEAN Other-Questionnaire	Modified
232419	4. MUSE Rapid Reflect Caregiver 7.9.18 CLEAN Other-Questionnaire	Modified
232418	3. MUSE Caregiver 6 12 Month Follow-Up Survey 7.25.18 CLEAN Other-Follow Up Survey	Modified
232417	2. MUSE Caregiver Baseline Survey 7.25.18 CLEAN Other-Caregiver Baseline Survey	Modified
232416	1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN Other-Enrollment Form	Modified

ICR Details

OMB Control No: 0970-0521	ICR Reference No: 201902-0970-010
Status: Historical Active	Previous ICR Reference No: 201807-0970-020
Agency/Subagency: HHS/ACF	Agency Tracking No:
Title: Multi-Site Implementation Evaluation of Tribal Home Visiting
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/06/2019
	Date Received in OIRA: 02/28/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2021	12/31/2021	12/31/2021
Responses	7,752	0	7,752
Time Burden (Hours)	2,240	0	2,240
Cost Burden (Dollars)	0	0	0

---

Abstract: This non-substantive change request includes updates to materials for the Multi-Site Implementation Study of Tribal Home Visiting (MUSE). Changes include submission of updated instruments as agreed upon during passback; updates to attachments to reflect minor procedural changes; and revisions to the supporting statements to incorporate changes related to instruments, minor procedural changes, and very minor edits.

---

Authorizing Statute(s): US Code: 42 USC 711 Name of Law: Social Security Act Title V, Section 511 (42 USC section 711)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 8681	02/28/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 39759	08/10/2018
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 16

IC Title	Form No.	Form Name
9. MUSE Local Program Evaluator Survey 7.9.18 CLEAN
11. MUSE Home Visitor Interview Questions 7.9.18
13. MUSE Local Evaluator Interview Questions 7.9.18
15. MUSE Implementation Logs 7.9.18 CLEAN
6. MUSE Home Visitor Survey 7.25.18 CLEAN
8. MUSE Program Director Survey 7.25.18 CLEAN
10. Program Implementation Survey 7.9.18 CLEAN
4. MUSE Rapid Reflect Caregiver 7.9.18 CLEAN
7. MUSE Program Coordinator-Manager Survey 7.25.18 CLEAN
3. MUSE Caregiver 6 12 Month Follow-Up Survey 7.25.18 CLEAN
12. MUSE Program Coordinator-Manager and Program Director Interview Questions 7.9.18
14. MUSE Caregiver Interview Questions 7.9.18 CLEAN
16. MUSE Administrative Data Elements 7.26.18 CLEAN
1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN
2. MUSE Caregiver Baseline Survey 7.25.18 CLEAN
5. MUSE Rapid Reflect Home Visitor 7.25.18 CLEAN

---

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	7,752	7,752	0	0	0	0
Annual Time Burden (Hours)	2,240	2,240	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: This is a new information collection.

---

Annual Cost to Federal Government: $654,783

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  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:

(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: 02/28/2019

---