Forms and Documents

Document Name	Status
EHRs Subject Matter Expert Interview Form and Instruction	New
ADSC Services User Questionnaire Form and Instruction	New
RCC Services User Questionnaire Form and Instruction	New
Form 0920-0943 Data Retrieval Form	Removed
ADSC Provider Questionnaire Form and Instruction	Modified
RCC Provider Questionnaire Form and Instruction	Modified
Att I Human Subjects Research Determination .docx Supplementary Document	2022-05-25
Att H Services User CATI Confirmation and Prep Letters and emails.docx Supplementary Document	2022-05-25
Att G Prompting letters and emails.docx Supplementary Document	2022-05-25
Att F Provider Questionnaire letters.docx Supplementary Document	2022-05-25
2022 NPALS SS B 052522.docx Supporting Statement B	2022-05-25
Att E-4 Advance Package NCHS Strictly Confidential Brochure.docx Supplementary Document	2022-05-25
Att E-3 Advance Package Letters of Support.docx Supplementary Document	2022-05-25
Att E-2 Advance Package Resident and Participant NCHS Data Briefs.docx Supplementary Document	2022-05-25
Att E-1 Advance Package-NCHS Cover Letter with FAQs.docx Supplementary Document	2022-05-25
Att D-2 ADSC Question Changes.xlsx Supplementary Document	2022-05-25
Att D-1 RCC Question Changes.xlsx Supplementary Document	2022-05-25
Att B-1 Sixty-day Notice in Federal Register 01242022.pdf Supplementary Document	2022-05-25
Att A Public Health Service Act (306ab and 308d).docx Supplementary Document	2022-05-25
2022 NPALS SS A 052022.docx Supporting Statement A	2022-05-25

IC Document Collections

IC ID	Document Title	Status
253599	EHRs Subject Matter Expert Interview Form and Instruction	New
253598	ADSC Services User Questionnaire Form and Instruction	New
253597	RCC Services User Questionnaire Form and Instruction	New
242826	Data Retrieval Form	Removed
231011	ADSC Provider Questionnaire Form and Instruction	Modified
231010	RCC Provider Questionnaire Form and Instruction	Modified

ICR Details

OMB Control No:	ICR Reference No:
Status:	Previous ICR Reference No:
Agency/Subagency:	Agency Tracking No:
Title:
Type of Information Collection:	Common Form ICR:
Type of Review Request:	Date Received in OIRA:

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

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Abstract:

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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Number of Information Collection (IC) in this ICR: 0

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ICR Summary of Burden

	Total	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	0	0	0	0	0	0
Annual Time Burden (Hours)	0	0	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion:

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion:

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods?

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.    

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.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?

Is this ICR related to the Pandemic Response?

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Common Form ICR: 

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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:

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