Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Revised Survey of Obesity Programs - Web Version	Form	New	Available
Revised Survey of Obesity Programs - Word version	Form	New	Repair queued
Survey of Obesity Program - web version	Form	New	Available
Survey of Obesity Programs	Form	New	Available
Word version of Survey of Asthma Program Evaluators	Form	New	Available
Web Survey of Asthma Program Evaluators	Form	New	Available
Consent & Survey	Form	New	Available
Survey instrument (web version)	Form	New	Available
Survey Instrument (word version)	Form	New	Available
SURVEYS OF STLT AGENCIES.PART B.docx	Supporting Statement B	Uploaded 2011-01-05	Available
Appendix B Summary of data collection activities.pdf	Supplementary Document	Uploaded 2011-01-05	Available
Appendix A. Sample Questions.docx	Supplementary Document	Uploaded 2011-01-05	Available
Attachment 3. Comments and response to 60-day FRN.docx	Supplementary Document	Uploaded 2011-01-05	Available
Attachment 2. 60 day notice.pdf	Supplementary Document	Uploaded 2011-01-05	Available
Attachment 1.Public Health Service Act.doc	Supplementary Document	Uploaded 2011-01-05	Available
SURVEYS OF STLT AGENCIES PART A updated 03.15.docx	Supporting Statement A	Uploaded 2011-03-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199300	Survey of Health Professional Perceptions and Use of Center TRT Services	Form	New	Revised Survey of Obesity Programs - Web Version
199300	Survey of Health Professional Perceptions and Use of Center TRT Services	Form	New	Revised Survey of Obesity Programs - Word version
199300	Survey of Health Professional Perceptions and Use of Center TRT Services	Form	New	Survey of Obesity Program - web version
199300	Survey of Health Professional Perceptions and Use of Center TRT Services	Form	New	Survey of Obesity Programs
199086	Survey of State and Territorial Asthma Program Evaluators	Form	New	Word version of Survey of Asthma Program Evaluators
199086	Survey of State and Territorial Asthma Program Evaluators	Form	New	Web Survey of Asthma Program Evaluators
198805	Needs and Perceptions of Did You Know	Other-Screen Shots Web Survey	New
198805	Needs and Perceptions of Did You Know	Form	New	Consent & Survey
198347	Survey of Health Official Perceptions and Use of the CDC Prevention Status Report (PSR Survey)	Form	New	Survey instrument (web version)
198347	Survey of Health Official Perceptions and Use of the CDC Prevention Status Report (PSR Survey)	Form	New	Survey Instrument (word version)

ICR Details

OMB Control No: 0920-0879	ICR Reference No: 201102-0920-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/17/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/02/2011
Terms of Clearance: 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).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved
Responses	21,480	0	0
Time Burden (Hours)	40,080	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Disease Control and Prevention (CDC) requests approval to facilitate effective and timely 2-way communications and enhance CDCs flexibility in responding to public health events. CDC's relationship with state, local, tribal and territorial (STLT) governmental health officials/employees is key to its emergency preparedness, health promotion and disease prevention responsibilities.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 65353	10/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 2122	01/12/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Needs and Perceptions of Did You Know	none	Consent & Survey
Survey of Health Official Perceptions and Use of the CDC Prevention Status Report (PSR Survey)	none, none	Survey Instrument (word version) ,   Survey instrument (web version)
Survey of Health Professional Perceptions and Use of Center TRT Services	none, none, none, none	Survey of Obesity Programs ,   Survey of Obesity Program - web version ,   Revised Survey of Obesity Programs - Word version ,   Revised Survey of Obesity Programs - Web Version
Survey of State and Territorial Asthma Program Evaluators	none, none	Web Survey of Asthma Program Evaluators ,   Word version of Survey of Asthma Program Evaluators

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ICR Summary of Burden

table that charts list 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	21,480	0	0	21,480	0	0
Annual Time Burden (Hours)	40,080	0	0	40,080	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new data collection.

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Annual Cost to Federal Government: $113,249

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

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Common Form ICR:  No

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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: 02/02/2011

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