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
Card Sorting Assessment Instrument for the STLT Gateway	Form and Instruction	New	Available
STLT Gateway Website Assessment Questionnaire	Form and Instruction	New	Available
Public Health Law Program Needs Assessment	Form	New	Available
PHHSBG Assessment Questionnaire (administered electronically)	Form and Instruction	New	Repair queued
HHIAG Assessment - web	Form	New	Repair queued
HHIAG Assessment - word	Form	New	Available
Local Health Department MCH Zika Capacity Assessment	Form and Instruction	New	Available
Flight-Related TBCI Assessment	Form and Instruction	New	Available
Best Practices Evaluation: Telephone Interview Guide	Form and Instruction	New	Repair queued
Telephone Interview Guide	Form and Instruction	New	Available
STD AAPPS Assessment Tool	Form	New	Available
Prior Authorization Policies for Pediatric ADHD Medication Prescriptions	Form	New	Available
ASPR Temporary Reassignment Request	Form	New	Available
Assessment of the Effectiveness of Municipal Waste Left in Place Ordinances - Web Version	Form and Instruction	New	Available
Assessment of the TB Laboratory Aggregate Report	Form	New	Available
Form Attachment C Screen Shots of the Web-based SySSSFF Template	Form	New	Available
Form Attachment C Screen Shots of the Web-based Success Story Template	Form	New	Repair queued
Exercise Feedback Form	Form	New	Available
Exercise Findings Form	Form	New	Available
District Level In-Person Interview Guide	Form and Instruction	New	Available
State Level Phone Interview Guide	Form and Instruction	New	Available
Web-based Assessment Instrument	Form and Instruction	New	Available
Additional County Supplement	Form	New	Available
County Health Policy Implementation Assessment - Word Version	Form	New	Repair queued
County Health Policy Implementation Assessment - Multi-county - Web Version	Form	New	Available
County Health Policy Implementation Assessment - Single-County Web Version	Form	New	Available
Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment Survey	Form and Instruction	New	Available
Sexual Violence Prevention Strategy Description	Form	New	Available
DIS Enumeration Data Collection Instrument	Form and Instruction	New	Available
Form 16ADY D. Focus Group Interview Guide Instrument_CHSI	Form and Instruction	New	Available
Form 16ADY C. Focus Group Participant Recruitment Instrument_CHSI	Form and Instruction	New	Available
Form 16ADY B. Health Director Referral Instrument_CHSI	Form and Instruction	New	Available
Form 0920-0879 Attachment C - SBRL Instrument - Web Version Screen Shots	Form and Instruction	New	Available
Form 0920-0879 Attachment B- SBRL Instrument - Word Version	Form and Instruction	New	Available
Form 0920-0879 Att D Instrument Web Version	Form and Instruction	New	Available
Form 0920-0879 Att C InstrumentMSWord	Form and Instruction	New	Repair queued
Form 0920-16NK Att B_CSTEDWA Instrument (Web Version)	Form and Instruction	New	Available
Form 0920-16NK Att A_CSTEDWA Instrument (Word Version)	Form and Instruction	New	Repair queued
Interview Guide	Form and Instruction	New	Available
ECE State Indicator Report	Form and Instruction	New	Available
Survey - NCCDPHP Training Needs Assessment	Form and Instruction	New	Available
Contact Instrument - NCCDPHP Training Needs Assessment	Form and Instruction	New	Available
Survey Screenshots	Form	New	Available
PrEP Local Health Department Assessment	Form	New	Available
PrEP Local Health Department Assessment	Form	New	Available
CMI Measurement Tool	Form and Instruction	New	Repair queued
Section VII: Public Health and Immunization Workforce	Form and Instruction	New	Available
Section VI: Public Information and Communication	Form and Instruction	New	Available
Section V: Community Mitigation	Form and Instruction	New	Available
Section IV: Healthcare Systems	Form and Instruction	New	Available
Section II: Epidemiology and Laboratory	Form and Instruction	New	Available
Section III: Medical Care & Countermeasures	Form and Instruction	New	Available
Section I: Vaccination Planning	Form and Instruction	New	Available
PHEP Contact and Assessment Instrument/Email	Form and Instruction	New	Available
Emerging Issues for Private Wells - Word	Form	New	Available
EMerging Issues for Private Wells - CSTE Assessment	Form	New	Available
Epi-Aid Satisfaction and Impact Assessment - word version	Form	New	Available
Epi-Aid Satsifaction and Impact Assessment	Form	New	Repair queued
Planner Instrument	Form and Instruction	New	Available
LHD Instrument - Web	Form and Instruction	New	Available
Statement A for ICR 0920-0879 HHS_ASPE.docx	Supporting Statement A	Uploaded 2015-01-02	Available
8-60day published FRN O2C2_HHS ASPE addition_May 16 2014.pdf	Supplementary Document	Uploaded 2014-12-17	Available
Statement B for ICR 0920-0879 - ASPE added.docx	Supporting Statement B	Uploaded 2014-12-17	Available
ATTACHMENT A_Section 301 Public Health Service Act [42 USC 241].doc	Supplementary Document	Uploaded 2014-02-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
229001	Prescription Drug Overdose Prevention for States Program Assessment	Other-Interview Guide	New
228708	Usability and Needs Assessment of CDC's State, Tribal, Local, and Territorial Gateway Website	Form and Instruction	New	Card Sorting Assessment Instrument for the STLT Gateway
228708	Usability and Needs Assessment of CDC's State, Tribal, Local, and Territorial Gateway Website	Form and Instruction	New	STLT Gateway Website Assessment Questionnaire
228708	Usability and Needs Assessment of CDC's State, Tribal, Local, and Territorial Gateway Website	Other-Reference document: WORD version of Web Quesionnaire Conte	New
228417	'SSPRACTICE'	Other-WORD	New
228201	Public Health Law Program Needs Assessment	Form	New	Public Health Law Program Needs Assessment
227889	Preventive Health and Health Services Block Grant Assessment	Form and Instruction	New	PHHSBG Assessment Questionnaire (administered electronically)
227889	Preventive Health and Health Services Block Grant Assessment	Other-For Reference: WORD version of the questionnaire	New
227751	HIV Health Improvement Affinity Group Assessment	Form	New	HHIAG Assessment - web
227751	HIV Health Improvement Affinity Group Assessment	Form	New	HHIAG Assessment - word
227751	HIV Health Improvement Affinity Group Assessment	Other-Interview Guide	New
227385	Maternal and Child Health Zika Capacity Assessment	Form and Instruction	New	Local Health Department MCH Zika Capacity Assessment
227264	Assessment of the 2011 CDC Protocol Change for Flight-Related Tuberculosis Contact Investigations	Form and Instruction	New	Flight-Related TBCI Assessment
227173	Assessment of the 2014 Best Practices Guide for Comprehensive Tobacco Control Programs	Form and Instruction	New	Best Practices Evaluation: Telephone Interview Guide
226281	VCASSESS	Other-WORD	New
225575	Community Health Worker Certification: Effective Strategies and Potential Challenges	Form and Instruction	New	Telephone Interview Guide
225570	Assessment of the STD AAPPS Funding Program	Form	New	STD AAPPS Assessment Tool
225570	Assessment of the STD AAPPS Funding Program	Other-Interview Guide	New
224398	Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies	Form	New	Prior Authorization Policies for Pediatric ADHD Medication Prescriptions
223988	ASPR Temporary Reassignment Request	Form	New	ASPR Temporary Reassignment Request
223803	Assessment of Waste Left in Place (WLIP) Ordinances	Form and Instruction	New	Assessment of the Effectiveness of Municipal Waste Left in Place Ordinances - Web Version
223710	Assessment of the Tuberculosis Laboratory Aggregate Report	Form	New	Assessment of the TB Laboratory Aggregate Report
223692	Syndromic Surveillance: Success Stories from the Field Guide from Not CDC Funded State & Local Health Departments	Form	New	Screen Shots of the Web-based SySSSFF Template
223690	Syndromic Surveillance: Success Stories from the Field from NSSP Awardees	Form	New	Screen Shots of the Web-based Success Story Template
223272	HHS Region VI Virtual Tabletop Exercise Assessment	Form	New	Exercise Feedback Form
223272	HHS Region VI Virtual Tabletop Exercise Assessment	Form	New	Exercise Findings Form
223213	School Health Resources: Assessing Awareness, Satisfaction, and Utility	Form and Instruction	New	District Level In-Person Interview Guide
223213	School Health Resources: Assessing Awareness, Satisfaction, and Utility	Form and Instruction	New	State Level Phone Interview Guide
223213	School Health Resources: Assessing Awareness, Satisfaction, and Utility	Form and Instruction	New	Web-based Assessment Instrument
223011	genIC Cancer Survivorship Needs Assessment for NCCCProgram Grantees	Other-WORD	New
222576	GenIC XDRCI-COST	Instruction	New
221796	County Health Policy Implementation Assessment	Form	New	Additional County Supplement
221796	County Health Policy Implementation Assessment	Form	New	County Health Policy Implementation Assessment - Word Version
221796	County Health Policy Implementation Assessment	Form	New	County Health Policy Implementation Assessment - Multi-county - Web Version
221796	County Health Policy Implementation Assessment	Form	New	County Health Policy Implementation Assessment - Single-County Web Version
221702	Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment	Form and Instruction	New	Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment Survey
221571	Systematic Identification and Assessment of Sexual Violence Prevention Strategies	Form	New	Sexual Violence Prevention Strategy Description
221571	Systematic Identification and Assessment of Sexual Violence Prevention Strategies	Other-word	New
221362	STD/HIV Disease Intervention Specialist (DIS) Workforce Assessment	Form and Instruction	New	DIS Enumeration Data Collection Instrument
221270	Needs Assessment for Developing a Network of LEHPs	Other-WORD	New
221208	Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment	Form and Instruction	New	D. Focus Group Interview Guide Instrument_CHSI
221208	Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment	Form and Instruction	New	C. Focus Group Participant Recruitment Instrument_CHSI
221208	Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment	Form and Instruction	New	B. Health Director Referral Instrument_CHSI
221092	Special Bacteriology Reference Laboratory Assessment	Form and Instruction	New	Attachment C - SBRL Instrument - Web Version Screen Shots
221092	Special Bacteriology Reference Laboratory Assessment	Form and Instruction	New	Attachment B- SBRL Instrument - Word Version
220160	State & Local HH & LPP Programs: Baseline Profile Assessment	Form and Instruction	New	Att D Instrument Web Version
220160	State & Local HH & LPP Programs: Baseline Profile Assessment	Form and Instruction	New	Att C InstrumentMSWord
219997	Non-Infectious Drinking Water Issues CSTE	Form and Instruction	New	Att B_CSTEDWA Instrument (Web Version)
219997	Non-Infectious Drinking Water Issues CSTE	Form and Instruction	New	Att A_CSTEDWA Instrument (Word Version)
219903	Federally Unregulated Drinking Water Programs: Assessing Strategies Leading to Policy Change	Form and Instruction	New	Interview Guide
219814	Assessment of Health Dept. Antibiotic Stewardship Roles and Activities	Other-Interview Guide	New
218357	Waterborne Disease Prevention: State Program Assessment	Instruction	New
218345	Early Care and Education (ECE) State Indicator Assessment	Form and Instruction	New	ECE State Indicator Report
218009	State Chronic Disease Prevention and Control Programs: Training Needs	Form and Instruction	New	Survey - NCCDPHP Training Needs Assessment
218009	State Chronic Disease Prevention and Control Programs: Training Needs	Form and Instruction	New	Contact Instrument - NCCDPHP Training Needs Assessment
217936	Mass Gathering Outbreaks: Assessment of Frequency, Policy and Communication Strategies	Form	New	Survey Screenshots
217936	Mass Gathering Outbreaks: Assessment of Frequency, Policy and Communication Strategies	Instruction	New
217399	Public Health Preparedness Capabilities Assessment (PHEPCAPSUR)	Other-WORD	New
216988	Preexposure Prophylaxis: Local Health Dept. Assessment	Form	New	PrEP Local Health Department Assessment
216988	Preexposure Prophylaxis: Local Health Dept. Assessment	Form	New	PrEP Local Health Department Assessment
216739	Assessment of Tobacco Control Program (TCP) Infrastructure	Form and Instruction	New	CMI Measurement Tool
216542	School Health Resources Assessment: Awareness, Satisfaction, and Utility	Other-WORD	New
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	Section VII: Public Health and Immunization Workforce
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	Section VI: Public Information and Communication
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	Section V: Community Mitigation
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	Section IV: Healthcare Systems
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	Section II: Epidemiology and Laboratory
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	Section III: Medical Care & Countermeasures
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	Section I: Vaccination Planning
216036	State and Local Public Health Planners: Pandemic Preparedness Readiness	Form and Instruction	New	PHEP Contact and Assessment Instrument/Email
216011	RSB Product and STLT Preparedness Assessment	Other-WORD	New
215977	Emerging Issues for Private Wells - CSTE Assessment	Form	New	Emerging Issues for Private Wells - Word
215977	Emerging Issues for Private Wells - CSTE Assessment	Form	New	EMerging Issues for Private Wells - CSTE Assessment
215976	Epi-Aid Satisfaction and Impact Assessment	Form	New	Epi-Aid Satisfaction and Impact Assessment - word version
215976	Epi-Aid Satisfaction and Impact Assessment	Form	New	Epi-Aid Satsifaction and Impact Assessment
215642	NGWA_Intervention to Prevent Exposure to Contaminants in Drinking Water	Other-WORD	New
215612	BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments	Form and Instruction	New	Planner Instrument
215612	BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments	Form and Instruction	New	LHD Instrument - Web

ICR Details

OMB Control No: 0920-0879	ICR Reference No: 201412-0920-011
Status: Historical Active	Previous ICR Reference No: 201402-0920-018
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: 03/02/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/05/2015
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	03/31/2018	36 Months From Approved	04/30/2017
Responses	162,000	0	162,000
Time Burden (Hours)	162,000	0	162,000
Cost Burden (Dollars)	0	0	0

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Abstract: This revision is requested in order to add the Department of Health and Human Services' Office of the Assistant Secretary for Planning and Evaluation (ASPE) as a new user of this generic clearance.

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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:
	79 FR 28513	05/16/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 75555	12/18/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 47

table that charts list of burden

IC Title	Form No.	Form Name
'SSPRACTICE'
ASPR Temporary Reassignment Request	none	ASPR Temporary Reassignment Request
Assessment of Health Dept. Antibiotic Stewardship Roles and Activities
Assessment of Tobacco Control Program (TCP) Infrastructure	None	CMI Measurement Tool
Assessment of Waste Left in Place (WLIP) Ordinances	NA	Assessment of the Effectiveness of Municipal Waste Left in Place Ordinances - Web Version
Assessment of the 2011 CDC Protocol Change for Flight-Related Tuberculosis Contact Investigations	NA	Flight-Related TBCI Assessment
Assessment of the 2014 Best Practices Guide for Comprehensive Tobacco Control Programs	NA	Best Practices Evaluation: Telephone Interview Guide
Assessment of the STD AAPPS Funding Program	none	STD AAPPS Assessment Tool
Assessment of the Tuberculosis Laboratory Aggregate Report	none	Assessment of the TB Laboratory Aggregate Report
Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment	NA	Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment Survey
BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments	None, None	LHD Instrument - Web ,   Planner Instrument
Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment	16ADY, 16ADY, 16ADY	B. Health Director Referral Instrument_CHSI ,   C. Focus Group Participant Recruitment Instrument_CHSI ,   D. Focus Group Interview Guide Instrument_CHSI
Community Health Worker Certification: Effective Strategies and Potential Challenges	N/A	Telephone Interview Guide
County Health Policy Implementation Assessment	none, none, none, none	County Health Policy Implementation Assessment - Single-County Web Version ,   County Health Policy Implementation Assessment - Multi-county - Web Version ,   County Health Policy Implementation Assessment - Word Version ,   Additional County Supplement
Early Care and Education (ECE) State Indicator Assessment	NA	ECE State Indicator Report
Emerging Issues for Private Wells - CSTE Assessment	none, none	EMerging Issues for Private Wells - CSTE Assessment ,   Emerging Issues for Private Wells - Word
Epi-Aid Satisfaction and Impact Assessment	none, none	Epi-Aid Satsifaction and Impact Assessment ,   Epi-Aid Satisfaction and Impact Assessment - word version
Federally Unregulated Drinking Water Programs: Assessing Strategies Leading to Policy Change	NA	Interview Guide
GenIC XDRCI-COST
HHS Region VI Virtual Tabletop Exercise Assessment	none, none	Exercise Findings Form ,   Exercise Feedback Form
HIV Health Improvement Affinity Group Assessment	none, none	HHIAG Assessment - word ,   HHIAG Assessment - web
Mass Gathering Outbreaks: Assessment of Frequency, Policy and Communication Strategies	none	Survey Screenshots
Maternal and Child Health Zika Capacity Assessment	NA	Local Health Department MCH Zika Capacity Assessment
NGWA_Intervention to Prevent Exposure to Contaminants in Drinking Water
Needs Assessment for Developing a Network of LEHPs
Non-Infectious Drinking Water Issues CSTE	0920-16NK, 0920-16NK	Att A_CSTEDWA Instrument (Word Version) ,   Att B_CSTEDWA Instrument (Web Version)
Preexposure Prophylaxis: Local Health Dept. Assessment	none, none	PrEP Local Health Department Assessment ,   PrEP Local Health Department Assessment
Prescription Drug Overdose Prevention for States Program Assessment
Preventive Health and Health Services Block Grant Assessment	n/a	PHHSBG Assessment Questionnaire (administered electronically)
Public Health Law Program Needs Assessment	none	Public Health Law Program Needs Assessment
Public Health Preparedness Capabilities Assessment (PHEPCAPSUR)
RSB Product and STLT Preparedness Assessment
STD/HIV Disease Intervention Specialist (DIS) Workforce Assessment	NA	DIS Enumeration Data Collection Instrument
School Health Resources Assessment: Awareness, Satisfaction, and Utility
School Health Resources: Assessing Awareness, Satisfaction, and Utility	N/A, N/A, N/A	Web-based Assessment Instrument ,   State Level Phone Interview Guide ,   District Level In-Person Interview Guide
Special Bacteriology Reference Laboratory Assessment	0920-0879, 0920-0879	Attachment B- SBRL Instrument - Word Version ,   Attachment C - SBRL Instrument - Web Version Screen Shots
State & Local HH & LPP Programs: Baseline Profile Assessment	0920-0879, 0920-0879	Att C InstrumentMSWord ,   Att D Instrument Web Version
State Chronic Disease Prevention and Control Programs: Training Needs	NA, NA	Contact Instrument - NCCDPHP Training Needs Assessment ,   Survey - NCCDPHP Training Needs Assessment
State and Local Public Health Planners: Pandemic Preparedness Readiness	None, None, None, None, None, None, None, None	PHEP Contact and Assessment Instrument/Email ,   Section I: Vaccination Planning ,   Section III: Medical Care & Countermeasures ,   Section II: Epidemiology and Laboratory ,   Section IV: Healthcare Systems ,   Section V: Community Mitigation ,   Section VI: Public Information and Communication ,   Section VII: Public Health and Immunization Workforce
Syndromic Surveillance: Success Stories from the Field Guide from Not CDC Funded State & Local Health Departments	Attachment C	Screen Shots of the Web-based SySSSFF Template
Syndromic Surveillance: Success Stories from the Field from NSSP Awardees	Attachment C	Screen Shots of the Web-based Success Story Template
Systematic Identification and Assessment of Sexual Violence Prevention Strategies	none	Sexual Violence Prevention Strategy Description
Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies	N/A	Prior Authorization Policies for Pediatric ADHD Medication Prescriptions
Usability and Needs Assessment of CDC's State, Tribal, Local, and Territorial Gateway Website	n/a, n/a	STLT Gateway Website Assessment Questionnaire ,   Card Sorting Assessment Instrument for the STLT Gateway
VCASSESS
Waterborne Disease Prevention: State Program Assessment
genIC Cancer Survivorship Needs Assessment for NCCCProgram Grantees

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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	162,000	0	0	0	0
Annual Time Burden (Hours)	162,000	162,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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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: 01/05/2015

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