Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Online Assessment	Form	New	Available
Web instrument	Form	New	Available
POISON CENTERS Assessment Tool	Form and Instruction	New	Available
CRYPTOSPORIDIOSIS Assessment Tool	Form and Instruction	New	Available
Assessment on Ebola Inquiries and Preparedness	Form	New	Available
Public Health Preparedness Capabilities Assessment	Form	New	Available
SVIS - Immunization Info Systems Interview	Form	New	Available
SVIS - Immunization Info Systems Assessment	Form	New	Available
Water Feedback	Form	New	Available
Water Toolkit Assessment	Form	New	Available
Vector Control Assessment	Form	New	Available
PHP Assessment Screenshots	Form	New	Available
HHA Interview Script and Guide REVISED	Form and Instruction	New	Available
Survey screenshots	Form	New	Available
Data Collection Instrument	Form	New	Available
Form 0920-0879 IZPHD Attachment D -Interview Instrument- Phase 2	Form and Instruction	New	Available
Form 0920-0879 IZPHD Attachment C_Instrument- Word- Phase 1	Form and Instruction	New	Available
Form 0920-0879 IZPHD Attachment B_Instrument- Web-Phase 1	Form and Instruction	New	Available
Form 0920-0879 EHR Attachment C_Instrument- Word- Phase 1	Form and Instruction	New	Available
Form 0920-0879 EHR Attachment B_Interview Guide Counsel	Form and Instruction	New	Available
Form 0920-0879 EHR Attachment A_Interview Guide HAI-Epi_041514	Form and Instruction	New	Available
SURVEYS OF STLT AGENCIES PART B for 0879.docx	Supporting Statement B	Uploaded 2014-02-20	Available
ATTACHMENTB_OSC- Published 60 day FRN on Federal Register- 1031013.pdf	Supplementary Document	Uploaded 2014-02-20	Available
ATTACHMENT A_Section 301 Public Health Service Act [42 USC 241].doc	Supplementary Document	Uploaded 2014-02-20	Available
Statement A for ICR 0879_revised 2 20 14.docx	Supporting Statement A	Uploaded 2014-02-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214223	PSR	Other-Web	New
214217	Mobilizing for Action through Planning and Partnerships (MAPP): Outcomes	Form	New	Online Assessment
214216	Public Health Improvement Trainings (PHIT) Assessment	Form	New	Web instrument
214212	IZ CORE	Other-WORD	New
213759	Cryptosporidiosis: Diagnostic Laboratory and Reporting Practices (CRYPTO) AND Incidents in the National Poison Data System (POISON CENTERS)	Form and Instruction	New	POISON CENTERS Assessment Tool
213759	Cryptosporidiosis: Diagnostic Laboratory and Reporting Practices (CRYPTO) AND Incidents in the National Poison Data System (POISON CENTERS)	Form and Instruction	New	CRYPTOSPORIDIOSIS Assessment Tool
213482	Assessing Key Factors to Pharmacy Enrollments in the Vaccines for Children Program	Other-WORD	New
213377	Preparedness for Persons under Investigation for Ebola Virus Disease	Form	New	Assessment on Ebola Inquiries and Preparedness
213235	PH LAW	Other-WORD	New
213123	Services and Value of Immunization Info Systems and Public Health Emergency Preparedness Capabilities	Form	New	Public Health Preparedness Capabilities Assessment
213123	Services and Value of Immunization Info Systems and Public Health Emergency Preparedness Capabilities	Form	New	SVIS - Immunization Info Systems Interview
213123	Services and Value of Immunization Info Systems and Public Health Emergency Preparedness Capabilities	Form	New	SVIS - Immunization Info Systems Assessment
213041	STLT Ebola-Related Activities	Other-WORD	New
212871	Improving State and Local Vector Control Program Performance and School Health "Water Toolkit" Assessment	Form	New	Water Feedback
212871	Improving State and Local Vector Control Program Performance and School Health "Water Toolkit" Assessment	Form	New	Water Toolkit Assessment
212871	Improving State and Local Vector Control Program Performance and School Health "Water Toolkit" Assessment	Form	New	Vector Control Assessment
212548	Public Health Performance Assessment & Healthy Homes Needs Assessment	Form	New	PHP Assessment Screenshots
212548	Public Health Performance Assessment & Healthy Homes Needs Assessment	Form and Instruction	New	HHA Interview Script and Guide REVISED
212458	Natinal Public Health Improvement Initiative: Program Assessment	Other-WORD	New
211589	Effective Educational Campaigns for Private Well Owners	Form	New	Survey screenshots
211394	Reference Labs	Form	New	Data Collection Instrument
211315	Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	Form and Instruction	New	IZPHD Attachment D -Interview Instrument- Phase 2
211315	Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	Form and Instruction	New	IZPHD Attachment C_Instrument- Word- Phase 1
211315	Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	Form and Instruction	New	IZPHD Attachment B_Instrument- Web-Phase 1
211315	Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	Form and Instruction	New	EHR Attachment C_Instrument- Word- Phase 1
211315	Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	Form and Instruction	New	EHR Attachment B_Interview Guide Counsel
211315	Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	Form and Instruction	New	EHR Attachment A_Interview Guide HAI-Epi_041514

ICR Details

OMB Control No: 0920-0879	ICR Reference No: 201402-0920-018
Status: Historical Active	Previous ICR Reference No: 201110-0920-004
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: 04/04/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/28/2014
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).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved	04/30/2014
Responses	162,000	0	120,240
Time Burden (Hours)	162,000	0	64,440
Cost Burden (Dollars)	0	0	0

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Abstract: CDC requests approval for a revision to the respondent universe to include delegates acting on behalf of STLT health departments involved in the provision of essential public health services in the US.

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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:
	78 FR 65325	10/31/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 10526	02/25/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 16

table that charts list of burden

IC Title	Form No.	Form Name
Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879	EHR Attachment A_Interview Guide HAI-Epi_041514 ,   EHR Attachment B_Interview Guide Counsel ,   EHR Attachment C_Instrument- Word- Phase 1 ,   IZPHD Attachment B_Instrument- Web-Phase 1 ,   IZPHD Attachment C_Instrument- Word- Phase 1 ,   IZPHD Attachment D -Interview Instrument- Phase 2
Assessing Key Factors to Pharmacy Enrollments in the Vaccines for Children Program
Cryptosporidiosis: Diagnostic Laboratory and Reporting Practices (CRYPTO) AND Incidents in the National Poison Data System (POISON CENTERS)	None, None	CRYPTOSPORIDIOSIS Assessment Tool ,   POISON CENTERS Assessment Tool
Effective Educational Campaigns for Private Well Owners	none	Survey screenshots
IZ CORE
Improving State and Local Vector Control Program Performance and School Health "Water Toolkit" Assessment	none, none, none	Vector Control Assessment ,   Water Toolkit Assessment ,   Water Feedback
Mobilizing for Action through Planning and Partnerships (MAPP): Outcomes	none	Online Assessment
Natinal Public Health Improvement Initiative: Program Assessment
PH LAW
PSR
Preparedness for Persons under Investigation for Ebola Virus Disease	none	Assessment on Ebola Inquiries and Preparedness
Public Health Improvement Trainings (PHIT) Assessment	none	Web instrument
Public Health Performance Assessment & Healthy Homes Needs Assessment	none, none	PHP Assessment Screenshots ,   HHA Interview Script and Guide REVISED
Reference Labs	none	Data Collection Instrument
STLT Ebola-Related Activities
Services and Value of Immunization Info Systems and Public Health Emergency Preparedness Capabilities	none, none, none	SVIS - Immunization Info Systems Assessment ,   SVIS - Immunization Info Systems Interview ,   Public Health Preparedness Capabilities Assessment

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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	162,000	120,240	0	41,760	0	0
Annual Time Burden (Hours)	162,000	64,440	0	97,560	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 changes in burden are due to previous errors in the burden numbers that were corrected in a change request but not recorded in ICRAS. In addition, changes in estimates of the number of surveys as well as the average burden per respondent result in fewer annual responses and burden hours. For the requested 3 years of clearance, increases are requested.

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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

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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: 02/28/2014

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