Preexposure Prophylaxis: Local Health Dept. 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⚠️ Notice: This information collection may be referencing outdated material.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
Preexposure Prophylaxis: Local Health Dept. Assessment Form
PrEP Local Health Department Assessment Att B_Instrument Word Version.docx Form
PrEP Local Health Department Assessment Att. C_Instrument Web Version.pdf Form
1 LHD-PREP-SSA.docx Supporting Statement A IC Document
2 LHD-PREP-SSB.docx Supporting Statement B IC Document
Att A_LHD sample.docx Sample Selection IC Document
Att. D_Notification E-mail.docx Notification Email IC Document
Att. E_Reminder E-mails.docx Reminder Email IC Document
Att. F_Reminder Call Script.docx Reminder Script IC Document

Information Collection (IC) Details

IC Title:	Preexposure Prophylaxis: Local Health Dept. Assessment	Agency IC Tracking Number:	15AQA

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	PrEP Local Health Department Assessment	Att B_Instrument Word Version.docx		Yes	Yes	Fillable Fileable
Form	none	PrEP Local Health Department Assessment	Att. C_Instrument Web Version.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	1 LHD-PREP-SSA.docx	06/11/2015
Supporting Statement B	2 LHD-PREP-SSB.docx	06/11/2015
Sample Selection	Att A_LHD sample.docx	06/11/2015
Notification Email	Att. D_Notification E-mail.docx	06/11/2015
Reminder Email	Att. E_Reminder E-mails.docx	06/11/2015
Reminder Script	Att. F_Reminder Call Script.docx	06/11/2015

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