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Brief and OIRA conclusion
Common Form Info.
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
ICR Reference No:
Previous ICR Reference No:
Agency Tracking No:
Assurance and Certification of Compliance (NPRM)
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
Type of Review Request:
OIRA Conclusion Action:
Comment filed on proposed rule
Retrieve Notice of Action (NOA)
Date Received in OIRA:
Terms of Clearance:
OMB is withholding approval at this time. Prior to publication of the final rule, the agency should provide a summary of any comments related to the information collection and their response, including any changes made to the ICR as a result of comments. In addition, the agency must enter the correct burden estimates.
Inventory as of this Action
36 Months From Approved
Time Burden (Hours)
Cost Burden (Dollars)
Requiring certain recipients and applicants to assure and certify compliance serves two purposes. First, through the act of reading and reviewing the statutory requirements to which recipients or applicants assure and certify compliance, recipients would be apprised of their obligations under the applicable Federal health care conscience and associated anti-discrimination laws. Second, a recipient’s or applicant’s awareness of its obligation would increase the likelihood that it would comply with such laws and consequently afford entities and individuals protection of their conscience rights and protection from coercion or discrimination. Because of this awareness, the Department anticipates that proposed § 88.4 may generate changes in the policies, procedures, and operations of the persons and entities covered
42 USC 300a-7
Name of Law: Church Admendment
42 USC 238n
Name of Law: Coats-Snowe Amendment,
Pub.L. 115 - 31 507(d)
Name of Law: Consolidated Appropriations Act
Pub.L. 131 - 135 209
Name of Law: Weldon language applied to Medicare Advantage
42 USC 18023(c)
Name of Law: Affordable Care Act
Citations for New Statutory Requirements:
Associated Rulemaking Information
Stage of Rulemaking:
Federal Register Citation:
83 FR 3880
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
Number of Information Collection (IC) in this ICR:
88.4(a) (Review and sign assurance and certification)
88.4(a) (Review Policies and Procedures)
88.4(a) (Update Policies and Procedures; Train Workforce)
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:
Please see the response to question one, which outlines the proposed requirement at 45 C.F.R. § 88.4.
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)?
Common Form ICR:
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.