View Information Collection Request (ICR) Package
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FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
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 Generic ICR - OIRA Conclusion
OMB Control No:
0920-0879
ICR Reference No:
201412-0920-011
Status:
Historical Active
Previous ICR Reference No:
201402-0920-018
Agency/Subagency:
HHS/CDC
Agency Tracking No:
21460
Title:
Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
03/02/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/05/2015
Terms of Clearance:
Terms of clearance continue: Approved consisent with the understanding that CDC will use this generic specifically for routine communications with public health officials to assess capacity and needs. This would not be the vehicle for submitting ICRs for gathering information from grantees about program performance or gathering in-depth information about programmatic needs. For ICs submitted under this generic ICR, CDC agrees to submit individual colletions to OMB, along with all necessary supporting statements (to include information about research design and analysis, burden estimates, approaches to address non-response bias, etc).
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2018
36 Months From Approved
04/30/2017
Responses
162,000
0
162,000
Time Burden (Hours)
162,000
0
162,000
Cost Burden (Dollars)
0
0
0
Abstract:
This revision is requested in order to add the Department of Health and Human Services' Office of the Assistant Secretary for Planning and Evaluation (ASPE) as a new user of this generic clearance.
Authorizing Statute(s):
US Code:
42 USC 301
Name of Law: Public Health Service Act
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:
79 FR 28513
05/16/2014
30-day Notice:
Federal Register Citation:
Citation Date:
79 FR 75555
12/18/2014
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
47
IC Title
Form No.
Form Name
'SSPRACTICE'
ASPR Temporary Reassignment Request
none
ASPR Temporary Reassignment Request
Assessment of Health Dept. Antibiotic Stewardship Roles and Activities
Assessment of Tobacco Control Program (TCP) Infrastructure
None
CMI Measurement Tool
Assessment of Waste Left in Place (WLIP) Ordinances
NA
Assessment of the Effectiveness of Municipal Waste Left in Place Ordinances - Web Version
Assessment of the 2011 CDC Protocol Change for Flight-Related Tuberculosis Contact Investigations
NA
Flight-Related TBCI Assessment
Assessment of the 2014 Best Practices Guide for Comprehensive Tobacco Control Programs
NA
Best Practices Evaluation: Telephone Interview Guide
Assessment of the STD AAPPS Funding Program
none
STD AAPPS Assessment Tool
Assessment of the Tuberculosis Laboratory Aggregate Report
none
Assessment of the TB Laboratory Aggregate Report
Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment
NA
Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment Survey
BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments
None, None
LHD Instrument - Web
,
Planner Instrument
Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment
16ADY, 16ADY, 16ADY
B. Health Director Referral Instrument_CHSI
,
C. Focus Group Participant Recruitment Instrument_CHSI
,
D. Focus Group Interview Guide Instrument_CHSI
Community Health Worker Certification: Effective Strategies and Potential Challenges
N/A
Telephone Interview Guide
County Health Policy Implementation Assessment
none, none, none, none
County Health Policy Implementation Assessment - Single-County Web Version
,
County Health Policy Implementation Assessment - Multi-county - Web Version
,
County Health Policy Implementation Assessment - Word Version
,
Additional County Supplement
Early Care and Education (ECE) State Indicator Assessment
NA
ECE State Indicator Report
Emerging Issues for Private Wells - CSTE Assessment
none, none
EMerging Issues for Private Wells - CSTE Assessment
,
Emerging Issues for Private Wells - Word
Epi-Aid Satisfaction and Impact Assessment
none, none
Epi-Aid Satsifaction and Impact Assessment
,
Epi-Aid Satisfaction and Impact Assessment - word version
Federally Unregulated Drinking Water Programs: Assessing Strategies Leading to Policy Change
NA
Interview Guide
GenIC XDRCI-COST
HHS Region VI Virtual Tabletop Exercise Assessment
none, none
Exercise Findings Form
,
Exercise Feedback Form
HIV Health Improvement Affinity Group Assessment
none, none
HHIAG Assessment - word
,
HHIAG Assessment - web
Mass Gathering Outbreaks: Assessment of Frequency, Policy and Communication Strategies
none
Survey Screenshots
Maternal and Child Health Zika Capacity Assessment
NA
Local Health Department MCH Zika Capacity Assessment
NGWA_Intervention to Prevent Exposure to Contaminants in Drinking Water
Needs Assessment for Developing a Network of LEHPs
Non-Infectious Drinking Water Issues CSTE
0920-16NK, 0920-16NK
Att A_CSTEDWA Instrument (Word Version)
,
Att B_CSTEDWA Instrument (Web Version)
Preexposure Prophylaxis: Local Health Dept. Assessment
none, none
PrEP Local Health Department Assessment
,
PrEP Local Health Department Assessment
Prescription Drug Overdose Prevention for States Program Assessment
Preventive Health and Health Services Block Grant Assessment
n/a
PHHSBG Assessment Questionnaire (administered electronically)
Public Health Law Program Needs Assessment
none
Public Health Law Program Needs Assessment
Public Health Preparedness Capabilities Assessment (PHEPCAPSUR)
RSB Product and STLT Preparedness Assessment
STD/HIV Disease Intervention Specialist (DIS) Workforce Assessment
NA
DIS Enumeration Data Collection Instrument
School Health Resources Assessment: Awareness, Satisfaction, and Utility
School Health Resources: Assessing Awareness, Satisfaction, and Utility
N/A, N/A, N/A
Web-based Assessment Instrument
,
State Level Phone Interview Guide
,
District Level In-Person Interview Guide
Special Bacteriology Reference Laboratory Assessment
0920-0879, 0920-0879
Attachment B- SBRL Instrument - Word Version
,
Attachment C - SBRL Instrument - Web Version Screen Shots
State & Local HH & LPP Programs: Baseline Profile Assessment
0920-0879, 0920-0879
Att C InstrumentMSWord
,
Att D Instrument Web Version
State Chronic Disease Prevention and Control Programs: Training Needs
NA, NA
Contact Instrument - NCCDPHP Training Needs Assessment
,
Survey - NCCDPHP Training Needs Assessment
State and Local Public Health Planners: Pandemic Preparedness Readiness
None, None, None, None, None, None, None, None
PHEP Contact and Assessment Instrument/Email
,
Section I: Vaccination Planning
,
Section III: Medical Care & Countermeasures
,
Section II: Epidemiology and Laboratory
,
Section IV: Healthcare Systems
,
Section V: Community Mitigation
,
Section VI: Public Information and Communication
,
Section VII: Public Health and Immunization Workforce
Syndromic Surveillance: Success Stories from the Field Guide from Not CDC Funded State & Local Health Departments
Attachment C
Screen Shots of the Web-based SySSSFF Template
Syndromic Surveillance: Success Stories from the Field from NSSP Awardees
Attachment C
Screen Shots of the Web-based Success Story Template
Systematic Identification and Assessment of Sexual Violence Prevention Strategies
none
Sexual Violence Prevention Strategy Description
Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies
N/A
Prior Authorization Policies for Pediatric ADHD Medication Prescriptions
Usability and Needs Assessment of CDC's State, Tribal, Local, and Territorial Gateway Website
n/a, n/a
STLT Gateway Website Assessment Questionnaire
,
Card Sorting Assessment Instrument for the STLT Gateway
VCASSESS
Waterborne Disease Prevention: State Program Assessment
genIC Cancer Survivorship Needs Assessment for NCCCProgram Grantees
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
162,000
162,000
0
0
0
0
Annual Time Burden (Hours)
162,000
162,000
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:
Annual Cost to Federal Government:
$80,892
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
Agency Contact:
Carol Marsh 404 639-4773 cww6@cdc.gov
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:
01/05/2015