Information Collection

Preventive Health and Health Services Block Grant Assessment

IC 227889 under ICR 201412-0920-011 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment B - Instrument- Word Version.docx	Other-For Reference: WORD version of
PHHSBG Assessment Questionnaire (administered electronic Attachment C -Instrument-Web version.docx	Form and Instruction
PHHSBGEVAL-SSA Revised Final.DOCX Supporting Statement - Part A	IC Document
PHHSBGEVAL-SSB.DOCX Supporting Statement - Part B	IC Document
Attachment A- List of PHHSBG Coordinators.docx List of PHHSBG Coordinators	IC Document
Attachment D - Invitation Email.docx Invitation Email	IC Document
Attachment E - Reminder Email.docx Reminder Email	IC Document
Attachment F - Final Reminder Email.docx Final Reminder Email	IC Document

IC Title:

Preventive Health and Health Services Block Grant Assessment

Agency IC Tracking Number:

0920-17AYM

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-For Reference: WORD version of the questionnaire			Attachment B - Instrument- Word Version.docx		No		Paper Only
Form and Instruction	n/a	PHHSBG Assessment Questionnaire (administered electronically)	Attachment C -Instrument-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: 61

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	61	61
Annual IC Time Burden (Hours)	61	61
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement - Part A	PHHSBGEVAL-SSA Revised Final.DOCX	08/11/2017
Supporting Statement - Part B	PHHSBGEVAL-SSB.DOCX	08/11/2017
List of PHHSBG Coordinators	Attachment A- List of PHHSBG Coordinators.docx	08/11/2017
Invitation Email	Attachment D - Invitation Email.docx	08/11/2017
Reminder Email	Attachment E - Reminder Email.docx	08/11/2017
Final Reminder Email	Attachment F - Final Reminder Email.docx	08/11/2017

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