Information Collection

Prescription Drug Overdose Prevention for States Program Assessment

IC 229001 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⚠️ Notice: This information collection may be referencing outdated material.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 C_Instrument- Telephone Interview Guide.docx	Other-Interview Guide
PFS-EVAL-SSA.DOCX Supporting Statement A	IC Document
PFS-EVAL-SSB.docx Supporting Statement B	IC Document
Attachment A_List of PfS Awardees.docx List of Awardees	IC Document
Attachment B_PfS Strategies and Activities.docx Strategies and Activities	IC Document
Attachment D_Recruitment E-mail.docx Recruitment Email	IC Document
Attachment E_Reminder E-mail.docx Reminder Email	IC Document
Attachment F_Confirmation E-mail.docx Confirmation Email	IC Document
Attachment G_Follow-up E-mail.docx Follow-up Email	IC Document

IC Title:

Prescription Drug Overdose Prevention for States Program Assessment

Agency IC Tracking Number:

0920-0879-18FK

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-Interview Guide			Attachment C_Instrument- Telephone Interview Guide.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 87

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	87	87
Annual IC Time Burden (Hours)	174	174
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	PFS-EVAL-SSA.DOCX	11/13/2017
Supporting Statement B	PFS-EVAL-SSB.docx	11/13/2017
List of Awardees	Attachment A_List of PfS Awardees.docx	11/13/2017
Strategies and Activities	Attachment B_PfS Strategies and Activities.docx	11/13/2017
Recruitment Email	Attachment D_Recruitment E-mail.docx	11/13/2017
Reminder Email	Attachment E_Reminder E-mail.docx	11/13/2017
Confirmation Email	Attachment F_Confirmation E-mail.docx	11/13/2017
Follow-up Email	Attachment G_Follow-up E-mail.docx	11/13/2017

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