65514 Federal Register / Vol. 76, No. 204 / Friday, October 21, 2011 / Notices 

ESTIMATED ANNUALIZED BURDEN HOURS

Type of respondent Form name Number of 

respondents 

Number of 

responses 

per 

respondent 

Average 

burden per 

response 

(hours) 

Student Program Participant ........................... Student Outcome Survey Baseline—Appendix D.9600 1 1.5 

Student Program Participant ........................... Student Outcome Survey Follow-up—Appendix E.9600 2 1.5 

School data extractor ...................................... School Indicators—Appendix F ...................... 48 200 15/60 

Parent Program Participant ............................ Parent Outcome Survey—Appendix G .......... 5760 2 1 

Educator .......................................................... Educator Outcome Survey—Appendix H ...... 1632 1 30/60 

Student Brand ambassador ............................ Brand Ambassador Implementation Survey— 

Appendix I.

80 2 20/60 

School leadership ........................................... School Leadership Capacity and Readiness 

Survey—Appendix J.

48 1 1 

Parent Curricula Implementer (6th grade) ...... Parent Program Fidelity 6th Grade Sessions 

1–5—Appendices K, L, M, N, O.

280 3 15/60 

Parent Curricula Implementer (7th grade) ...... Parent Program Fidelity 7th Grade Sessions 

1, 3–5—Appendices P, Q, R.

168 3 15/60 

Safe Dates Implementer (implementation) ..... Safe Dates Implementation Survey—Appendix S.144 1 1 

Student Curricula Implementer (6th grade) .... Student Program Fidelity 6th Grade Session 

1–6—Appendices T, U, V, W, X, Y.

1728 1 15/60 

Student Curricula Implementer (7th grade) .... Student Program Fidelity 7th Grade Sessions 1–6—Appendices Z–EE.1728 1 15/60 

Student Curricula Implementer (8th grade) .... Student Program Fidelity 8th Grade Sessions 1–10—Appendices FF–OO.2880 1 15/60 

Communications Implementer ........................ Communications Campaign Tracking—Appendix PP.4 4 20/60 

Local health department representative ......... Local Health Department Capacity and 

Readiness—Appendix QQ.

16 1 2 

Parent Program Manager ............................... Parent Program Capacity and Readiness— 

Appendix RR.

4 1 1 

Community Representative ............................. Community Capacity and Readiness—Appendix SS.40 1 1 

Catina Conner, 

Acting Reports Clearance Officer, Centers for 

Disease Control and Prevention. 

[FR Doc. 2011–27245 Filed 10–20–11; 8:45 am] 

BILLING CODE 4163–18–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10291 and CMS– 

10403] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services, HHS. 

In compliance with the requirement 

of section 3506(c)(2)(A) of the 

Paperwork Reduction Act of 1995, the 

Centers for Medicare & Medicaid 

Services (CMS), Department of Health 

and Human Services, is publishing the 

following summary of proposed 

collections for public comment. 

Interested persons are invited to send 

comments regarding this burden 

estimate or any other aspect of this 

collection of information, including any 

of the following subjects: (1) The 

necessity and utility of the proposed 

information collection for the proper 

performance of the Agency’s function; 

(2) the accuracy of the estimated 

burden; (3) ways to enhance the quality, 

utility, and clarity of the information to 

be collected; and (4) the use of 

automated collection techniques or 

other forms of information technology to 

minimize the information collection 

burden. 

1. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: State Collection 

and Reporting of Dental Provider and 

Benefit Package Information on the 

Insure Kids Now! Web site and Hotline; 

Use: The Children’s Health Insurance 

Program Reauthorization Act of 2009 

(CHIPRA) sections 501(f)(1) and (2), 

requires that state-specific information 

on dental providers and benefits be 

posted on the Insure Kids Now (IKN) 

Web site and available on the hotline. 

States must update the information on 

the dental providers quarterly and the 

information on their benefit package 

annually. CMS is asking States to 

submit their dental benefits in a revised 

format that is designed to reduce the 

amount of time States have to spend in 

compiling the dental benefit 

information. Although in the past we 

allowed States to only check a box to 

indicate that the Medicaid dental 

benefits were in compliance with Early 

and Periodic Screening, Diagnostic and 

Treatment (EPSDT) services, we are also 

modifying the form to ask States to 

include their Medicaid dental benefits 

in this form so those may also be posted 

on the Web site. In addition, we are 

asking States to specify if they have a 

dollar or code limit at which point prior 

authorization is required for any 

additional services and if they have cost 

sharing requirements for dental services; 

Form Number: CMS–10291 (OMB #: 

0938–1065); Frequency: Yearly (dental 

benefits) and quarterly (dental 

providers); Affected Public: State, Local, 

or Tribal Governments; Number of 

Respondents: 51; Total Annual 

Responses: 255; Total Annual Hours: 

190. (For policy questions regarding this 

collection contact Nancy Goetschius at 

410–786–0707. For all other issues call 

410–786–1326.) 

2. Type of Information Collection 

Request: New collection; Title of 

Information Collection: CommunityVerDate Mar<15>2010 18:11 Oct 20, 2011 Jkt 226001 PO 00000 Frm 00022 Fmt 4703 Sfmt 4703 E:\FR\FM\21OCN1.SGM 21OCN1

sroberts on DSK5SPTVN1PROD with NOTICES
Federal Register / Vol. 76, No. 204 / Friday, October 21, 2011 / Notices 65515 

based Care Transitions Program (CCTP) 

Implementation and Monitoring; Use: 

The Medicare Community-Based Care 

Transitions Program (CCTP), authorized 

by Section 3026 of the 2010 Affordable 

Care Act, is a major component of the 

Partnership for Patients initiative, one 

goal of which is to decrease preventable 

complications during transition from a 

care setting, such as a hospital, to home, 

community, or another care setting. 

Appendix A contains a copy of the 

relevant portion of the legislation. 

The CCTP will provide funding to test 

models for improving care transitions 

from the hospital to the community for 

high-risk Medicare beneficiaries. The 

Centers for Medicare & Medicaid 

Services (CMS) initiated the CCTP in 

early 2011 and will operate the program 

for five years. Congress has authorized 

$500 million to cover the cost of the 

program. CMS expects that program 

agreements will be in place to authorize 

community-based organizations (CBOs), 

in partnership with acute care hospitals, 

to begin providing care transition 

services in November 2011 and, if 

successful, continue doing so for up to 

five years. The planned collection of a 

participant experience survey is part of 

the implementation and monitoring 

strategy that will review the 

performance of organizations contracted 

to provide transitional care services 

under the CCTP. This clearance package 

seeks approval for the participant 

experience survey. 

Form Number: CMS–10403 (OMB # 

0938–New); Frequency: Once; Affected 

Public: Individuals or Households; 

Number of Respondents: 50,000; Total 

Annual Responses: 50,000; Total 

Annual Hours: 12,500. (For policy 

questions regarding this collection 

contact Juliana Tiongson at 410–786– 

0342. For all other issues call 410–786– 

1326.) 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS Web site 

address at http://www.cms.hhs.gov/ 

PaperworkReductionActof1995, or Email your request, including your 

address, phone number, OMB number, 

and CMS document identifier, to 

Paperwork@cms.hhs.gov, or call the 

Reports Clearance Office on (410) 786– 

1326. 

To be assured consideration, 

comments and recommendations for the 

proposed information collections must 

be received by the OMB desk officer at 

the address below, no later than 5 p.m. 

on November 21, 2011. 

OMB, Office of Information and 

Regulatory Affairs, Attention: CMS 

Desk Officer. 

Fax Number: (202) 395–6974. 

E-mail: 

OIRA_submission@omb.eop.gov. 

Dated: October 18, 2011. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–27300 Filed 10–20–11; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10249] 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services, HHS. 

In compliance with the requirement 

of section 3506(c)(2)(A) of the 

Paperwork Reduction Act of 1995, the 

Centers for Medicare & Medicaid 

Services (CMS) is publishing the 

following summary of proposed 

collections for public comment. 

Interested persons are invited to send 

comments regarding this burden 

estimate or any other aspect of this 

collection of information, including any 

of the following subjects: (1) The 

necessity and utility of the proposed 

information collection for the proper 

performance of the agency’s functions; 

(2) the accuracy of the estimated 

burden; (3) ways to enhance the quality, 

utility, and clarity of the information to 

be collected; and (4) the use of 

automated collection techniques or 

other forms of information technology to 

minimize the information collection 

burden. 

1. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: Administrative 

Requirements for Section 6071 of the 

Deficit Reduction Act; Use: Under 

section 6071 of the Deficit Reduction 

Act of 2005 (P.L. 109–171) subsection 

(c), the Secretary may require States to 

meet requirements and provide 

additional information, provisions, and 

assurances. Through the Operational 

Protocol, States provide the 

requirements, information, provisions 

and assurances which, following CMS 

approval, States may enroll individuals 

in the State’s demonstration program or 

begin to claim for service dollars. The 

Act also requires the Money Follows the 

Person Rebalancing Demonstration 

(MFP) program be evaluated to 

determine program effectiveness. One 

aspect of the evaluation is determining 

participant quality of life and how the 

program affects quality of life. Medicaid 

enrollees who participate in the MFP 

program are expected to have need for 

long-term care services for the rest of 

their lives and are a particularly 

vulnerable population if the community 

setting cannot adequately meet their 

needs or does not provide them a 

suitable quality of life. 

State Operational Protocols should 

provide enough information that: the 

CMS Project Officer and other Federal 

officials may use it to understand the 

operation of the demonstration and/or 

prepare for potential site visits without 

needing additional information; the 

State Project Director can use it as the 

manual for program implementation; 

and external stakeholders may use it to 

understand the operation of the 

demonstration. The financial 

information collection will be used in 

CMS financial statements and shared 

with the auditors who validate CMS’ 

financial position. The Maintenance of 

Effort forms as well as the MFP Budget 

Form are required each year. 

Submissions of MFP Demonstration 

Financial Forms are 90 days after the 

end of each Federal fiscal quarter. The 

MFP Finders File, MFP Program 

Participation Data file, and MFP 

Services File will be used by the 

national evaluation contractor to assess 

program outcomes. The MFP Quality of 

Life data will be used by the national 

evaluation contractor to assess program 

outcomes. Specifically, the evaluation 

will determine how participants’ quality 

of life changes after transitioning to the 

community. The semi-annual progress 

reports will be used by the national 

evaluation contractor and CMS to 

monitor program implementation at the 

grantee level; Form Number: CMS– 

10249 (OCN: 0938–1053); Frequency: 

Yearly, Semi-annually, Quarterly, Once; 

Affected Public: State, Local, or Tribal 

Governments; Number of Respondents: 

43; Total Annual Responses: 360; Total 

Annual Hours: 9,360. (For policy 

questions regarding this collection 

contact Marybeth Ribar at 410–786– 

1121. For all other issues call 410–786– 

1326.) 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS’ Web Site 

address at http://www.cms.hhs.gov/ 

PaperworkReductionActof1995, or Email your request, including your 

address, phone number, OMB number, 

and CMS document identifier, to 

Paperwork@cms.hhs.gov, or call the 


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