Public Health Practice Stories from the Field

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
PHPSFF Attachment A - Story Collection Template_REVISED 032612.docx Other-Word
PHPSFF Attachment B - Sample PHPSFF_New Jersey NPHII v031612.pdf Att B_Sample PHPSFF IC Document
PHPSFF Attachment C - Gateway for State, Tribal, Local and Territorial Public Health Professionals.docx Att C Screen Shots IC Document
PHPSFF Attachment D - Vital Signs Town Hall Teleconference.docx Att D Teleconference Screen Shots IC Document
PHPSFF Attachment E - Notification Email.docx Att E Notification E-mail IC Document
PHPSFF Attachment F - Reminders - Email and Telephone.docx Att F Reminders IC Document
PHPSFF Supporting Statement A v031612.docx Supporting Statement A IC Document
PHPSFF Supporting Statement B v031612.docx Supporting Statement B IC Document

Information Collection (IC) Details

IC Title:	Public Health Practice Stories from the Field	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Word			PHPSFF Attachment A - Story Collection Template_REVISED 032612.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 276	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	276	0	0	0	0	0
Annual IC Time Burden (Hours)	1,932	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att B_Sample PHPSFF	PHPSFF Attachment B - Sample PHPSFF_New Jersey NPHII v031612.pdf	03/26/2012
Att C Screen Shots	PHPSFF Attachment C - Gateway for State, Tribal, Local and Territorial Public Health Professionals.docx	03/26/2012
Att D Teleconference Screen Shots	PHPSFF Attachment D - Vital Signs Town Hall Teleconference.docx	03/26/2012
Att E Notification E-mail	PHPSFF Attachment E - Notification Email.docx	03/26/2012
Att F Reminders	PHPSFF Attachment F - Reminders - Email and Telephone.docx	03/26/2012
Supporting Statement A	PHPSFF Supporting Statement A v031612.docx	03/26/2012
Supporting Statement B	PHPSFF Supporting Statement B v031612.docx	03/26/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.