Public Health Performance Assessment & Healthy Homes Needs Assessment

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

⚠️ Notice: This information collection may be referencing outdated material.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
Public Health Performance Assessment & Healthy Homes Needs Assessment Form and Instruction
PHP Assessment Screenshots PHPIPA Assessment Web Version.docx Form
HHA Interview Script and Guide REVISED HHNA Interview Script and Guide rev.docx Form and Instruction
PHPIPA-SSA rev.docx PHP SS Part A IC Document
PHPIPA-SSB.docx PHP SS Part B IC Document
PHPI Multi-State Learning Collaborative.pdf PHP Learning Collaborative IC Document
PHPI NPHII Fact Sheet.pdf PHP Fact Sheet IC Document
PHPI PIM Network Factsheet.pdf PHP Network Fact Sheet IC Document
PHPI Recruitment Email.docx PHP Recruitment Email IC Document
PHPI Reminder Email.docx PHP Reminder Email IC Document
PHPIPA Assessment Word Version.docx PHP Assessment - Word Version IC Document
HHNA-SSA rev.docx HH SS Part A IC Document
HHNA-SSB.docx HH SS Part B IC Document
HHNA Risk by State Locality.docx HH Risk by State IC Document
HHNA Introductory CDC Email.docx HH Introductory Email IC Document
HHNA Doodle Scheduling Email.docx HH Scheduling Email IC Document
HHNA Scheduling Confirmation Email.docx HH Confirmation Email IC Document
HHNA Reminder Email.docx HH Reminder Email IC Document

Information Collection (IC) Details

IC Title:	Public Health Performance Assessment & Healthy Homes Needs Assessment	Agency IC Tracking Number:	14ARP/14ARQ

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 and Instruction	none	HHA Interview Script and Guide REVISED	HHNA Interview Script and Guide rev.docx		No		Paper Only
Form	none	PHP Assessment Screenshots	PHPIPA Assessment Web Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,784	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,784	1,784
Annual IC Time Burden (Hours)	449	449
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
PHP SS Part A	PHPIPA-SSA rev.docx	08/29/2014
PHP SS Part B	PHPIPA-SSB.docx	07/31/2014
PHP Learning Collaborative	PHPI Multi-State Learning Collaborative.pdf	07/31/2014
PHP Fact Sheet	PHPI NPHII Fact Sheet.pdf	07/31/2014
PHP Network Fact Sheet	PHPI PIM Network Factsheet.pdf	07/31/2014
PHP Recruitment Email	PHPI Recruitment Email.docx	07/31/2014
PHP Reminder Email	PHPI Reminder Email.docx	07/31/2014
PHP Assessment - Word Version	PHPIPA Assessment Word Version.docx	07/31/2014
HH SS Part A	HHNA-SSA rev.docx	08/29/2014
HH SS Part B	HHNA-SSB.docx	07/31/2014
HH Risk by State	HHNA Risk by State Locality.docx	07/31/2014
HH Introductory Email	HHNA Introductory CDC Email.docx	07/31/2014
HH Scheduling Email	HHNA Doodle Scheduling Email.docx	07/31/2014
HH Confirmation Email	HHNA Scheduling Confirmation Email.docx	07/31/2014
HH Reminder Email	HHNA Reminder Email.docx	07/31/2014

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