Assessment of State Public Health Department Immunization Billing Reimbursement Projects

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⚠️ Notice: This information collection may be referencing outdated material.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
Assessment of State Public Health Department Immunization Billing Reimbursement Projects Form
Billables Project Assessment Attachment G-Data Collection Instrument Web Version.docx Form
IZ Billing Supporting_Statement_A_amended 11 14 13.docx Supporting Statement Part A IC Document
IZ Billing Supporting_Statement_B_amended 11 14 13.docx Supporting Statement Part B IC Document
Attachment H-Data Collection Instrument MS Word Version.docx Billables Project Assessment Word Version IC Document
Attachment A-NVAC Vaccine Financing Recommendations.pdf Vaccine Financing Recommendations IC Document
Attachment B-Data CDC-funded awardees map.docx Funded Awardees Map IC Document
Attachment C -Billables Program Plan.docx Billables Program Plan IC Document
Attachment D-NACCHO report.pdf NACCHO Report IC Document
Attachment E- ASTHO article.pdf ASTHO Article IC Document
Attachment F-American Journal of Preventive Medicine article.pdf Journal Article IC Document
Attachment I- Billables Contact list docx.doc Billables Contact List IC Document
Attachment J - Introductory Email.docx Introductory Email IC Document
Attachment K - Follow-up Email.docx Follow-up Email IC Document

Information Collection (IC) Details

IC Title:	Assessment of State Public Health Department Immunization Billing Reimbursement Projects	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
Form	none	Billables Project Assessment	Attachment G-Data Collection Instrument Web Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	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 Agency Discretion
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement Part A	IZ Billing Supporting_Statement_A_amended 11 14 13.docx	11/14/2013
Supporting Statement Part B	IZ Billing Supporting_Statement_B_amended 11 14 13.docx	11/14/2013
Billables Project Assessment Word Version	Attachment H-Data Collection Instrument MS Word Version.docx	11/14/2013
Vaccine Financing Recommendations	Attachment A-NVAC Vaccine Financing Recommendations.pdf	11/14/2013
Funded Awardees Map	Attachment B-Data CDC-funded awardees map.docx	11/14/2013
Billables Program Plan	Attachment C -Billables Program Plan.docx	11/14/2013
NACCHO Report	Attachment D-NACCHO report.pdf	11/14/2013
ASTHO Article	Attachment E- ASTHO article.pdf	11/14/2013
Journal Article	Attachment F-American Journal of Preventive Medicine article.pdf	11/14/2013
Billables Contact List	Attachment I- Billables Contact list docx.doc	11/14/2013
Introductory Email	Attachment J - Introductory Email.docx	11/14/2013
Follow-up Email	Attachment K - Follow-up Email.docx	11/14/2013

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