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

Forms and Documents

Document Name	Status
Public Health Law Program Needs Assessment Form	New
HIV Health Improvement Affinity Group Assessment Form	New
Maternal and Child Health Zika Capacity Assessment Form and Instruction	New
Assessment of the 2011 CDC Protocol Change for Flight-Related Tuberculosis Contact Investigations Form and Instruction	New
Assessment of the 2014 Best Practices Guide for Comprehensive Tobacco Control Programs Form and Instruction	New
Community Health Worker Certification: Effective Strategies and Potential Challenges Form and Instruction	New
Assessment of the STD AAPPS Funding Program Form	New
Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies Form	New
ASPR Temporary Reassignment Request Form	New
Assessment of Waste Left in Place (WLIP) Ordinances Form and Instruction	New
Assessment of the Tuberculosis Laboratory Aggregate Report Form	New
Form Attachment C Syndromic Surveillance: Success Stories from the Field Guide from Not CDC Funded State & Local Health Departments Form	New
Form Attachment C Syndromic Surveillance: Success Stories from the Field from NSSP Awardees Form	New
HHS Region VI Virtual Tabletop Exercise Assessment Form	New
School Health Resources: Assessing Awareness, Satisfaction, and Utility Form and Instruction	New
County Health Policy Implementation Assessment Form	New
Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment Form and Instruction	New
STD/HIV Disease Intervention Specialist (DIS) Workforce Assessment Form and Instruction	New
Form 16ADY Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment Form and Instruction	New
Form 0920-0879 Special Bacteriology Reference Laboratory Assessment Form and Instruction	New
Form 0920-0879 State & Local HH & LPP Programs: Baseline Profile Assessment Form and Instruction	New
Form 0920-16NK Non-Infectious Drinking Water Issues CSTE Form and Instruction	New
Federally Unregulated Drinking Water Programs: Assessing Strategies Leading to Policy Change Form and Instruction	New
Early Care and Education (ECE) State Indicator Assessment Form and Instruction	New
State Chronic Disease Prevention and Control Programs: Training Needs Form and Instruction	New
Mass Gathering Outbreaks: Assessment of Frequency, Policy and Communication Strategies Form	New
Preexposure Prophylaxis: Local Health Dept. Assessment Form	New
Assessment of Tobacco Control Program (TCP) Infrastructure Form and Instruction	New
State and Local Public Health Planners: Pandemic Preparedness Readiness Form and Instruction	New
Emerging Issues for Private Wells - CSTE Assessment Form	New
Epi-Aid Satisfaction and Impact Assessment Form	New
BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments Form and Instruction	New
Statement A for ICR 0920-0879 HHS_ASPE.docx Supporting Statement A	2015-01-02
8-60day published FRN O2C2_HHS ASPE addition_May 16 2014.pdf Supplementary Document	2014-12-17
Statement B for ICR 0920-0879 - ASPE added.docx Supporting Statement B	2014-12-17
ATTACHMENT A_Section 301 Public Health Service Act [42 USC 241].doc Supplementary Document	2014-02-20

IC Document Collections

IC ID	Document Title	Status
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 Other-Reference document: WORD version of Web Quesionnaire Conte	New
228417	'SSPRACTICE' Other-WORD	New
228201	Public Health Law Program Needs Assessment Form	New
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
227385	Maternal and Child Health Zika Capacity Assessment Form and Instruction	New
227264	Assessment of the 2011 CDC Protocol Change for Flight-Related Tuberculosis Contact Investigations Form and Instruction	New
227173	Assessment of the 2014 Best Practices Guide for Comprehensive Tobacco Control Programs Form and Instruction	New
226281	VCASSESS Other-WORD	New
225575	Community Health Worker Certification: Effective Strategies and Potential Challenges Form and Instruction	New
225570	Assessment of the STD AAPPS Funding Program Form	New
224398	Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies Form	New
223988	ASPR Temporary Reassignment Request Form	New
223803	Assessment of Waste Left in Place (WLIP) Ordinances Form and Instruction	New
223710	Assessment of the Tuberculosis Laboratory Aggregate Report Form	New
223692	Syndromic Surveillance: Success Stories from the Field Guide from Not CDC Funded State & Local Health Departments Form	New
223690	Syndromic Surveillance: Success Stories from the Field from NSSP Awardees Form	New
223272	HHS Region VI Virtual Tabletop Exercise Assessment Form	New
223213	School Health Resources: Assessing Awareness, Satisfaction, and Utility Form and Instruction	New
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
221702	Awareness and Practice of Disaster Risk Reduction for Health: A National Assessment Form and Instruction	New
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
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
221092	Special Bacteriology Reference Laboratory Assessment Form and Instruction	New
220160	State & Local HH & LPP Programs: Baseline Profile Assessment Form and Instruction	New
219997	Non-Infectious Drinking Water Issues CSTE Form and Instruction	New
219903	Federally Unregulated Drinking Water Programs: Assessing Strategies Leading to Policy Change Form and Instruction	New
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
218009	State Chronic Disease Prevention and Control Programs: Training Needs Form and Instruction	New
217936	Mass Gathering Outbreaks: Assessment of Frequency, Policy and Communication Strategies Form	New
217399	Public Health Preparedness Capabilities Assessment (PHEPCAPSUR) Other-WORD	New
216988	Preexposure Prophylaxis: Local Health Dept. Assessment Form	New
216739	Assessment of Tobacco Control Program (TCP) Infrastructure Form and Instruction	New
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
216011	RSB Product and STLT Preparedness Assessment Other-WORD	New
215977	Emerging Issues for Private Wells - CSTE Assessment Form	New
215976	Epi-Aid Satisfaction and Impact Assessment Form	New
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

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
	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).

	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

IC Title	Form No.	Form Name
Assessment of Tobacco Control Program (TCP) Infrastructure	None	CMI Measurement Tool
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
State & Local HH & LPP Programs: Baseline Profile Assessment	0920-0879, 0920-0879	Att C InstrumentMSWord ,   Att D Instrument Web Version
Assessment of the 2014 Best Practices Guide for Comprehensive Tobacco Control Programs	NA	Best Practices Evaluation: Telephone Interview Guide
NGWA_Intervention to Prevent Exposure to Contaminants in Drinking Water
Emerging Issues for Private Wells - CSTE Assessment	none, none	EMerging Issues for Private Wells - CSTE Assessment ,   Emerging Issues for Private Wells - Word
BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments	None, None	LHD Instrument - Web ,   Planner Instrument
VCASSESS
Maternal and Child Health Zika Capacity Assessment	NA	Local Health Department MCH Zika Capacity Assessment
Public Health Law Program Needs Assessment	none	Public Health Law Program Needs Assessment
'SSPRACTICE'
Usability and Needs Assessment of CDC's State, Tribal, Local, and Territorial Gateway Website	n/a, n/a	Card Sorting Assessment Instrument for the STLT Gateway ,   STLT Gateway Website Assessment Questionnaire
Epi-Aid Satisfaction and Impact Assessment	none, none	Epi-Aid Satsifaction and Impact Assessment ,   Epi-Aid Satisfaction and Impact Assessment - word version
Needs Assessment for Developing a Network of LEHPs
STD/HIV Disease Intervention Specialist (DIS) Workforce Assessment	NA	DIS Enumeration Data Collection Instrument
School Health Resources: Assessing Awareness, Satisfaction, and Utility	N/A, N/A, N/A	State Level Phone Interview Guide ,   Web-based Assessment Instrument ,   District Level In-Person Interview Guide
ASPR Temporary Reassignment Request	none	ASPR Temporary Reassignment Request
Community Health Worker Certification: Effective Strategies and Potential Challenges	N/A	Telephone Interview Guide
Waterborne Disease Prevention: State Program Assessment
School Health Resources Assessment: Awareness, Satisfaction, and Utility
Federally Unregulated Drinking Water Programs: Assessing Strategies Leading to Policy Change	NA	Interview Guide
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
Special Bacteriology Reference Laboratory Assessment	0920-0879, 0920-0879	Attachment B- SBRL Instrument - Word Version ,   Attachment C - SBRL Instrument - Web Version Screen Shots
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
HHS Region VI Virtual Tabletop Exercise Assessment	none, none	Exercise Findings Form ,   Exercise Feedback Form
Assessment of the STD AAPPS Funding Program	none	STD AAPPS Assessment Tool
Systematic Identification and Assessment of Sexual Violence Prevention Strategies	none	Sexual Violence Prevention Strategy Description
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
Assessment of the Tuberculosis Laboratory Aggregate Report	none	Assessment of the TB Laboratory Aggregate Report
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
HIV Health Improvement Affinity Group Assessment	none, none	HHIAG Assessment - word ,   HHIAG Assessment - web
Preexposure Prophylaxis: Local Health Dept. Assessment	none, none	PrEP Local Health Department Assessment ,   PrEP Local Health Department Assessment
RSB Product and STLT Preparedness Assessment
Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies	N/A	Prior Authorization Policies for Pediatric ADHD Medication Prescriptions
Public Health Preparedness Capabilities Assessment (PHEPCAPSUR)
Assessment of Health Dept. Antibiotic Stewardship Roles and Activities
Non-Infectious Drinking Water Issues CSTE	0920-16NK, 0920-16NK	Att B_CSTEDWA Instrument (Web Version) ,   Att A_CSTEDWA Instrument (Word Version)
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
Preventive Health and Health Services Block Grant Assessment	n/a	PHHSBG Assessment Questionnaire (administered electronically)
Prescription Drug Overdose Prevention for States Program Assessment
Mass Gathering Outbreaks: Assessment of Frequency, Policy and Communication Strategies	none	Survey Screenshots
State Chronic Disease Prevention and Control Programs: Training Needs	NA, NA	Contact Instrument - NCCDPHP Training Needs Assessment ,   Survey - NCCDPHP Training Needs Assessment
Early Care and Education (ECE) State Indicator Assessment	NA	ECE State Indicator Report
genIC Cancer Survivorship Needs Assessment for NCCCProgram Grantees
GenIC XDRCI-COST
Syndromic Surveillance: Success Stories from the Field from NSSP Awardees	Attachment C	Screen Shots of the Web-based Success Story Template

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ICR Summary 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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