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
Assessment of Guidelines for HIV Testing in Refugees	Form	New	Available
ISP Assessment	Form	New	Available
ISP PM Data Collection	Form	New	Available
TB Instrument - Web	Form	New	Available
Survey for Microbiolgist	Form	New	Available
Survey for Epidemiologist	Form	New	Available
Interview Guide - Epidemiologist	Form	New	Available
Interview Guide - PI	Form	New	Available
Partner Interview	Form and Instruction	New	Available
Supervisor Interview	Form and Instruction	New	Available
Billables Project Assessment	Form	New	Available
Assess Breast and Cervical Cancer Screening Program Activities	Form	New	Available
Attachment G--Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff--Web-version	Form and Instruction	New	Available
Attachment F: Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff-Word Version	Form and Instruction	New	Available
Health Department Homeless TB Data Collection Instrument--Screenshots	Form	New	Available
Health Department Homeless TB Data Collection Instrument	Form	New	Available
Form 0920-0879 STD Field Staff ATTACHMENT C Instrument-Online	Form and Instruction	New	Available
Form 0920-0879 STD Field Staff ATTACHMENT B Instrument	Form and Instruction	New	Available
Assessment of Public Health Veterinarians Regarding the Sale, Display, and Exhibition of "Exotic" Animals	Form and Instruction	New	Available
Att H - Focus Group Script	Form and Instruction	New	Available
Att G - Screenshots of Doodle Poll	Form	New	Available
Att E - Focus Group Scheduling Email	Form and Instruction	New	Available
Form 0920-0879 EHDI- Attachment G- Self Assessment Follow up	Form and Instruction	New	Available
Form 0920-0879 EHDI- Attachment D- Data Collection Instrument Word version	Form and Instruction	New	Available
Form 0920-0879 EHDI- Attachment C- Data Collection Instrument web version	Form and Instruction	New	Repair queued
Att H - TA Satisfaction Screen Shots	Form	New	Available
Focus Group Guide	Form and Instruction	New	Available
Assessment of Principal Grant Contacts	Form	New	Available
Assessment of STLT Grantee SAS Users	Form	New	Available
Awareness and Use of EAPO Products	Form	New	Available
Newborn Screening Program Survey	Form	New	Available
Newborn Screening Lab Survey	Form	New	Available
CG Web Survey - screenshots	Form	New	Available
CG Web Survey - Word	Form	New	Available
Att H - Survey Screenshots	Form and Instruction	New	Available
Att G - Survey Instrument	Form and Instruction	New	Available
Form 0920-0879 Attachment N Email with survey link	Form and Instruction	New	Available
Form 0920-0879 Attachment M Email notification 10312012	Form and Instruction	New	Available
Form 0920-0879 AttachmentJ - Questionnaire WORD version	Form and Instruction	New	Available
Form 0920-0879 Attachment K Screen shot of questionnaire	Form and Instruction	New	Available
NPHII Annual Assessment	Form	New	Available
Birth Certificate and Hospital Discharge - NAPHSIS	Form	New	Available
Birth Certificate and Hospital Discharge Survey - AMCHP	Form	New	Available
IMATS Web Survey	Form	New	Available
CPPW Web Survey	Form	New	Available
Survey Reminder Emails	Form	New	Available
Survey Notification Email	Form	New	Available
Survey Web Screenshots	Form	New	Available
Survey (Web)	Form	New	Available
Survey (Word)	Form	New	Available
Form 3 PanFlu Survey	Form and Instruction	New	Available
Form 2 PH Law web survey	Form and Instruction	New	Available
Form 1 PH Law Survey	Form and Instruction	New	Available
Form 4 PanFlu Web Survey	Form and Instruction	New	Available
CDC ID Reference Labs Customer Satisfaction Survey	Form	New	Available
Drug Susceptability Test Results	Form	New	Available
Evaluation of Detection of Drug Resistance Testing Service	Form	New	Available
Assessment of CDC Guidelines for the Field Triage of Injured Patients	Form	New	Available
Justification for Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-09-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
210377	Internet Partner Service Activities and Guidelines for HIV Testing at Refugee Screening	Form	New	Assessment of Guidelines for HIV Testing in Refugees
210377	Internet Partner Service Activities and Guidelines for HIV Testing at Refugee Screening	Form	New	ISP Assessment
210377	Internet Partner Service Activities and Guidelines for HIV Testing at Refugee Screening	Form	New	ISP PM Data Collection
210158	SHD Reporting (14EU) and Testing Practices and TB Elimination FOA (14GS)	Form	New	TB Instrument - Web
210158	SHD Reporting (14EU) and Testing Practices and TB Elimination FOA (14GS)	Form	New	Survey for Microbiolgist
210158	SHD Reporting (14EU) and Testing Practices and TB Elimination FOA (14GS)	Form	New	Survey for Epidemiologist
210065	Biosense Submission Processes Assessment	Instruction	New
209699	Utility and Value of Flexible Epidemiologists	Form	New	Interview Guide - Epidemiologist
209699	Utility and Value of Flexible Epidemiologists	Form	New	Interview Guide - PI
209625	Health Department Use and Application of CDC Drug Resistant TB Laboratory Services	Other-WORD	New
209499	Case Study of the Career Epidemiology Field Officer Assignments in Three State Health Department	Form and Instruction	New	Partner Interview
209499	Case Study of the Career Epidemiology Field Officer Assignments in Three State Health Department	Form and Instruction	New	Supervisor Interview
209489	Assessment of State Public Health Department Immunization Billing Reimbursement Projects	Form	New	Billables Project Assessment
209207	Assess Breast and Cervical Cancer Screening Program Activities to Expand Access to Screening	Form	New	Assess Breast and Cervical Cancer Screening Program Activities
208834	Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff	Form and Instruction	New	Attachment G--Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff--Web-version
208834	Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff	Form and Instruction	New	Attachment F: Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff-Word Version
208743	Assessing Effectiveness Brochure: LHD/NHHE Progam Working Together AND STD Prevention Services	Other-WORD	New
208544	Assessment of Local Health Departments' Interventions to Address TB among Persons Experiencing Homelessness	Form	New	Health Department Homeless TB Data Collection Instrument--Screenshots
208544	Assessment of Local Health Departments' Interventions to Address TB among Persons Experiencing Homelessness	Form	New	Health Department Homeless TB Data Collection Instrument
208251	Assessment of State/Local STD Clinic Directors Perceptions and Attitudes Regarding CDC Field Staff	Form and Instruction	New	STD Field Staff ATTACHMENT C Instrument-Online
208251	Assessment of State/Local STD Clinic Directors Perceptions and Attitudes Regarding CDC Field Staff	Form and Instruction	New	STD Field Staff ATTACHMENT B Instrument
206474	Assessment of Public Health Veterinarians Regarding the Sale, Display, and Exhibition of "Exotic" Animals	Other-Screenshots of Attachment B	New
206474	Assessment of Public Health Veterinarians Regarding the Sale, Display, and Exhibition of "Exotic" Animals	Form and Instruction	New	Assessment of Public Health Veterinarians Regarding the Sale, Display, and Exhibition of "Exotic" Animals
206223	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems: Focus Groups	Form and Instruction	New	Att H - Focus Group Script
206223	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems: Focus Groups	Form	New	Att G - Screenshots of Doodle Poll
206223	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems: Focus Groups	Form and Instruction	New	Att E - Focus Group Scheduling Email
206181	Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators	Form and Instruction	New	EHDI- Attachment G- Self Assessment Follow up
206181	Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators	Form and Instruction	New	EHDI- Attachment D- Data Collection Instrument Word version
206181	Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators	Instruction	New
206181	Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators	Form and Instruction	New	EHDI- Attachment C- Data Collection Instrument web version
206096	Assessments of the Quality and Utility of National Public Health Improvement Initiative to Support STLT	Form	New	Att H - TA Satisfaction Screen Shots
206096	Assessments of the Quality and Utility of National Public Health Improvement Initiative to Support STLT	Form and Instruction	New	Focus Group Guide
205915	Assessing Analytic Tools and Practices of STLT Health Dept. Data Analysts	Form	New	Assessment of Principal Grant Contacts
205915	Assessing Analytic Tools and Practices of STLT Health Dept. Data Analysts	Form	New	Assessment of STLT Grantee SAS Users
205850	Assessment of Awareness and Use of Epidemiology and Analysis Program Office Products	Form	New	Awareness and Use of EAPO Products
205658	State and Local Environmental Public Health Employees Usage of Public Health Assessments and Consultations Documents	Instruction	New
205467	Assessing the Needs and Capacity of State Newborn Screening Programs and Laboratories	Form	New	Newborn Screening Program Survey
205467	Assessing the Needs and Capacity of State Newborn Screening Programs and Laboratories	Form	New	Newborn Screening Lab Survey
205300	Assessing the Utility of the Community Guide Website and Products Among STLT Email Subscribers	Form	New	CG Web Survey - screenshots
205300	Assessing the Utility of the Community Guide Website and Products Among STLT Email Subscribers	Form	New	CG Web Survey - Word
205029	National Outbreak Reporting System: An Evaluation of Foodborne Disease Outbreak Surveillance and Technical Requirements for Reporting	Form and Instruction	New	Att H - Survey Screenshots
205029	National Outbreak Reporting System: An Evaluation of Foodborne Disease Outbreak Surveillance and Technical Requirements for Reporting	Form and Instruction	New	Att G - Survey Instrument
204845	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems	Form and Instruction	New	Attachment N Email with survey link
204845	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems	Form and Instruction	New	Attachment M Email notification 10312012
204845	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems	Instruction	New
204845	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems	Form and Instruction	New	AttachmentJ - Questionnaire WORD version
204845	Assessment of Characteristics of State Crash Outcome Data Evaluation Systems	Form and Instruction	New	Attachment K Screen shot of questionnaire
204461	Assessment of Performance Management and Improvement Practices	Form	New	NPHII Annual Assessment
203899	Birth Certificate and Hospital Discharge Linkage - State Survey	Form	New	Birth Certificate and Hospital Discharge - NAPHSIS
203899	Birth Certificate and Hospital Discharge Linkage - State Survey	Form	New	Birth Certificate and Hospital Discharge Survey - AMCHP
203549	CPPW Resource Center Feedback Assessment and IMATS Assessment	Form	New	IMATS Web Survey
203549	CPPW Resource Center Feedback Assessment and IMATS Assessment	Form	New	CPPW Web Survey
203097	Technical Assistance and Service Improvement Initiative (TASII)	Form	New	Survey Reminder Emails
203097	Technical Assistance and Service Improvement Initiative (TASII)	Form	New	Survey Notification Email
203097	Technical Assistance and Service Improvement Initiative (TASII)	Form	New	Survey Web Screenshots
202600	Evaluating the Health Hazard Evaluation Program's Communication with Local Health Departments	Form	New	Survey (Web)
202600	Evaluating the Health Hazard Evaluation Program's Communication with Local Health Departments	Form	New	Survey (Word)
202480	Public Health Law Training and Technical Assistance Needs Assessment and Pandemic Influenza Nonpharmaceutical Interventions	Form and Instruction	New	PanFlu Survey
202480	Public Health Law Training and Technical Assistance Needs Assessment and Pandemic Influenza Nonpharmaceutical Interventions	Form and Instruction	New	PH Law web survey
202480	Public Health Law Training and Technical Assistance Needs Assessment and Pandemic Influenza Nonpharmaceutical Interventions	Form and Instruction	New	PH Law Survey
202480	Public Health Law Training and Technical Assistance Needs Assessment and Pandemic Influenza Nonpharmaceutical Interventions	Form and Instruction	New	PanFlu Web Survey
201730	Public Health Practice Stories from the Field	Other-Word	New
201010	CDC Infectious Diseases Reference Laboratories Customer Satisfaction Survey	Form	New	CDC ID Reference Labs Customer Satisfaction Survey
200731	Evaluation of CDC Service Provided to Public Health Labs to Rapidly Identify Multidrug-Resistant Isolates of TB	Form	New	Drug Susceptability Test Results
200731	Evaluation of CDC Service Provided to Public Health Labs to Rapidly Identify Multidrug-Resistant Isolates of TB	Form	New	Evaluation of Detection of Drug Resistance Testing Service
199821	CDC Guidelines for the Field Triage of Injured Patients: National Evaluation	Form	New	Assessment of CDC Guidelines for the Field Triage of Injured Patients

ICR Details

OMB Control No: 0920-0879	ICR Reference No: 201110-0920-004
Status: Historical Active	Previous ICR Reference No: 201102-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/14/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/13/2011
Terms of Clearance: Terms of clearance continue: roved 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	03/31/2014	03/31/2014
Responses	120,240	0	21,480
Time Burden (Hours)	64,440	0	40,080
Cost Burden (Dollars)	0	0	0

---

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.

---

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

Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 33

table that charts list of burden

IC Title	Form No.	Form Name
Assess Breast and Cervical Cancer Screening Program Activities to Expand Access to Screening	none	Assess Breast and Cervical Cancer Screening Program Activities
Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff	None, None	Attachment F: Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff-Word Version ,   Attachment G--Assessing Satisfaction and Utility of OSTLTS Communication Products for Health Department Staff--Web-version
Assessing Analytic Tools and Practices of STLT Health Dept. Data Analysts	none, none	Assessment of STLT Grantee SAS Users ,   Assessment of Principal Grant Contacts
Assessing Effectiveness Brochure: LHD/NHHE Progam Working Together AND STD Prevention Services
Assessing the Needs and Capacity of State Newborn Screening Programs and Laboratories	none, none	Newborn Screening Lab Survey ,   Newborn Screening Program Survey
Assessing the Utility of the Community Guide Website and Products Among STLT Email Subscribers	none, none	CG Web Survey - Word ,   CG Web Survey - screenshots
Assessment of Awareness and Use of Epidemiology and Analysis Program Office Products	none	Awareness and Use of EAPO Products
Assessment of Characteristics of State Crash Outcome Data Evaluation Systems	0920-0879, 0920-0879, 0920-0879, 0920-0879	Attachment K Screen shot of questionnaire ,   AttachmentJ - Questionnaire WORD version ,   Attachment M Email notification 10312012 ,   Attachment N Email with survey link
Assessment of Characteristics of State Crash Outcome Data Evaluation Systems: Focus Groups	none, none, none	Att E - Focus Group Scheduling Email ,   Att G - Screenshots of Doodle Poll ,   Att H - Focus Group Script
Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators	0920-0879, 0920-0879, 0920-0879	EHDI- Attachment C- Data Collection Instrument web version ,   EHDI- Attachment D- Data Collection Instrument Word version ,   EHDI- Attachment G- Self Assessment Follow up
Assessment of Local Health Departments' Interventions to Address TB among Persons Experiencing Homelessness	None, None	Health Department Homeless TB Data Collection Instrument ,   Health Department Homeless TB Data Collection Instrument--Screenshots
Assessment of Performance Management and Improvement Practices	none	NPHII Annual Assessment
Assessment of Public Health Veterinarians Regarding the Sale, Display, and Exhibition of "Exotic" Animals	none	Assessment of Public Health Veterinarians Regarding the Sale, Display, and Exhibition of "Exotic" Animals
Assessment of State Public Health Department Immunization Billing Reimbursement Projects	none	Billables Project Assessment
Assessment of State/Local STD Clinic Directors Perceptions and Attitudes Regarding CDC Field Staff	0920-0879, 0920-0879	STD Field Staff ATTACHMENT B Instrument ,   STD Field Staff ATTACHMENT C Instrument-Online
Assessments of the Quality and Utility of National Public Health Improvement Initiative to Support STLT	none, none	Focus Group Guide ,   Att H - TA Satisfaction Screen Shots
Biosense Submission Processes Assessment
Birth Certificate and Hospital Discharge Linkage - State Survey	none, none	Birth Certificate and Hospital Discharge Survey - AMCHP ,   Birth Certificate and Hospital Discharge - NAPHSIS
CDC Guidelines for the Field Triage of Injured Patients: National Evaluation	none	Assessment of CDC Guidelines for the Field Triage of Injured Patients
CDC Infectious Diseases Reference Laboratories Customer Satisfaction Survey	none	CDC ID Reference Labs Customer Satisfaction Survey
CPPW Resource Center Feedback Assessment and IMATS Assessment	none, none	CPPW Web Survey ,   IMATS Web Survey
Case Study of the Career Epidemiology Field Officer Assignments in Three State Health Department	none, none	Supervisor Interview ,   Partner Interview
Evaluating the Health Hazard Evaluation Program's Communication with Local Health Departments	none, none	Survey (Word) ,   Survey (Web)
Evaluation of CDC Service Provided to Public Health Labs to Rapidly Identify Multidrug-Resistant Isolates of TB	none, none	Evaluation of Detection of Drug Resistance Testing Service ,   Drug Susceptability Test Results
Health Department Use and Application of CDC Drug Resistant TB Laboratory Services
Internet Partner Service Activities and Guidelines for HIV Testing at Refugee Screening	none, none, none	ISP PM Data Collection ,   ISP Assessment ,   Assessment of Guidelines for HIV Testing in Refugees
National Outbreak Reporting System: An Evaluation of Foodborne Disease Outbreak Surveillance and Technical Requirements for Reporting	none, none	Att G - Survey Instrument ,   Att H - Survey Screenshots
Public Health Law Training and Technical Assistance Needs Assessment and Pandemic Influenza Nonpharmaceutical Interventions	1, 2, 3, 4	PH Law Survey ,   PH Law web survey ,   PanFlu Survey ,   PanFlu Web Survey
Public Health Practice Stories from the Field
SHD Reporting (14EU) and Testing Practices and TB Elimination FOA (14GS)	none, none, none	Survey for Epidemiologist ,   Survey for Microbiolgist ,   TB Instrument - Web
State and Local Environmental Public Health Employees Usage of Public Health Assessments and Consultations Documents
Technical Assistance and Service Improvement Initiative (TASII)	none, none, none	Survey Web Screenshots ,   Survey Notification Email ,   Survey Reminder Emails
Utility and Value of Flexible Epidemiologists	none, none	Interview Guide - PI ,   Interview Guide - Epidemiologist

---

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	120,240	21,480	0	98,760	0	0
Annual Time Burden (Hours)	64,440	40,080	0	24,360	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: The original submission was in error in requesting the annualized burden for this generic rather than the entire 3 years of estimated burden. This change request is for the complete 3 years of estimated burden.

---

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

---

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: 10/13/2011

---