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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.