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

Forms and Documents

Document Name	Status
Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot Form and Instruction	New
Community of Practice Member Satisfaction and Needs Assessment Form	New
2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey Form and Instruction	New
Assessment of STLT Public Health Agencies to Guide the Update of CDC/ATSDR Cancer Cluster Guidelines Form	New
NCCCP Program Improvement Assessment Form	New
Assessment of the National Health Security Index for Public Health Preparedness Form	New
CDC Newborn Screening Quality Assurance Program – Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot Form and Instruction	New
Vector Surveillance and Control Assessment: Post Zika-Response and Tick Capacities (VECTOR-PZ) Form and Instruction	New
Form 0920-20PD Determining the Landscape of QMSs for PHLs Performing NGS (LD) Form and Instruction	New
HIV Partner Services HIPEP Assessment Form	New
Form 0920-0879 Pre-Hospital Stroke Systems of Care: Emergency Medical Service System (EMSS) Implementation Assessment Form and Instruction	New
Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations (CMG-EVAL) Form and Instruction	New
NSSP BioSense Platform User Assessment: Functionality and Utility Form and Instruction	New
NOFO: Assessment of Language and Structure Form	New
Form 0920-0879 SLPHERLT Form and Instruction	New
EBP-PHPR Form	New
State Oral Health and Chronic Disease Programs Integration Assessment Form and Instruction	New
Form 0920-0879 PHEP Success Story Assessment Form and Instruction	New
Form 0920-0879 Public Health in Indian Country Capacity Scan Assessment (PHICCS) Form and Instruction	New
Form 0920-0879 DROUGHT-IC Form and Instruction	New
Form 0920-0879 Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction Form and Instruction	New
Form 0920-0879 Environmental Health Workforce Current and Emerging Challenges Assessment Form and Instruction	New
Form 0920-0879 The State of State Suicide Prevention: An Environmental Scan Form and Instruction	New
Prevention and Control of Shigellosis: A Needs Assessment of State and Local Health Departments Form and Instruction	New
STD Prevention and Control: Workplan Template Pilot Form	New
Form 0920-0879 Public Health Ethics Activities at State and Local Health Departments: Current Status and Challenges Form and Instruction	New
National Syndromic Surveillance Program Community of Practice Assessment Form	New
Attachment B_Approved GenICs under 0920-0879 updated 112017.docx Supplementary Document	2017-11-20
Statement B for 0920-0879 ICR updated 112017.docx Supporting Statement B	2017-11-20
Statement A for 0920-0879 ICR_updated 112017.docx Supporting Statement A	2017-11-20
Attachment A Public Health Service Act.doc Supplementary Document	2017-11-20

IC Document Collections

IC ID	Document Title	Status
244433	Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot Form and Instruction	New
243890	Community of Practice Member Satisfaction and Needs Assessment Form	New
243827	2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey Form and Instruction	New
242670	Assessment of STLT Public Health Agencies to Guide the Update of CDC/ATSDR Cancer Cluster Guidelines Form	New
242474	Assessment of Colorectal Cancer Control Program Implementation at Health System Clinic Sites Other-Web Version	New
242393	NCCCP Program Improvement Assessment Form	New
242255	Assessment of the National Health Security Index for Public Health Preparedness Form	New
242252	CDC Newborn Screening Quality Assurance Program – Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot Form and Instruction	New
242191	Vector Surveillance and Control Assessment: Post Zika-Response and Tick Capacities (VECTOR-PZ) Form and Instruction	New
242187	Determining the Landscape of QMSs for PHLs Performing NGS (LD) Form and Instruction	New
241449	HIV Partner Services HIPEP Assessment Form	New
240830	RAWMILKPR - Unpasteurized Milk Outbreaks: An Assessment of the Legal Landscape, Outbreak Investigations, and Prevention at the State Leve Other-Screenshots	New
238256	CDC Project Officer Support: SHD Officials Assessment Other-WORD	New
236818	Pre-Hospital Stroke Systems of Care: Emergency Medical Service System (EMSS) Implementation Assessment Form and Instruction	New
236347	Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations (CMG-EVAL) Form and Instruction	New
236064	NSSP BioSense Platform User Assessment: Functionality and Utility Form and Instruction	New
235662	NOFO: Assessment of Language and Structure Form	New
234911	SLPHERLT Form and Instruction	New
234422	EBP-PHPR Form	New
234047	State Oral Health and Chronic Disease Programs Integration Assessment Form and Instruction	New
233547	State Oral Health Program Assessment Other-Word version of the Online Survey (for reference)	New
233545	PHEP Success Story Assessment Form and Instruction	New
232932	Public Health in Indian Country Capacity Scan Assessment (PHICCS) Form and Instruction	New
232671	DROUGHT-IC Form and Instruction	New
232124	Qualitative Assessment of CDC-funded Local Health Dept Violence Prevention Efforts Other-Interview Guide	New
231786	Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction Form and Instruction	New
231592	Environmental Health Workforce Current and Emerging Challenges Assessment Form and Instruction	New
231591	The State of State Suicide Prevention: An Environmental Scan Form and Instruction	New
231555	Medical Countermearsure Training Needs Assessment Other-Electronic Version	New
231502	Prevention and Control of Shigellosis: A Needs Assessment of State and Local Health Departments Form and Instruction	New
231342	STD Prevention and Control: Workplan Template Pilot Form	New
231324	Public Health Ethics Activities at State and Local Health Departments: Current Status and Challenges Form and Instruction	New
231188	National Syndromic Surveillance Program Community of Practice Assessment Form	New

ICR Details

OMB Control No: 0920-0879	ICR Reference No: 201711-0920-012
Status: Active	Previous ICR Reference No: 201412-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/17/2018
	Date Received in OIRA: 11/21/2017
Terms of Clearance: Previous 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	01/31/2021	36 Months From Approved	03/31/2018
Responses	162,000	0	162,000
Time Burden (Hours)	162,000	0	162,000
Cost Burden (Dollars)	3,763,260	0	0

---

Abstract: CDC requests an extension to the generic clearance to continue to collect information related to domestic public health issues and services that affect state, tribal, local, and territorial STLT governmental entities.

---

Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 19371	04/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 40583	08/25/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 33

IC Title	Form No.	Form Name
Pre-Hospital Stroke Systems of Care: Emergency Medical Service System (EMSS) Implementation Assessment	0920-0879	Interview Guide
Public Health Ethics Activities at State and Local Health Departments: Current Status and Challenges	0920-0879, 0920-0879	Online Survey Instrument_Web version ,   Telephone Interview Guide
State Oral Health Program Assessment	n/a, n/a	Online Survey (screen captures) ,   Telephone Interview Guide for State Oral Health Staff
National Syndromic Surveillance Program Community of Practice Assessment	none, none	Community of Practice Assessment - word ,   Community of Practice - web
Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot	none, none	Data Reporting Page ,   Feedback Form
Assessment of Colorectal Cancer Control Program Implementation at Health System Clinic Sites	0920-20PX	Colo-rectal Cancer Control Program Survey
SLPHERLT	0920-0879, 0920-0879	Web-Based Assessment ,   Focus Group Facilitation Guide
DROUGHT-IC	0920-0879	DROUGHT Preparedness and Response Assessment Tool (DEMO)
State Oral Health and Chronic Disease Programs Integration Assessment	n/a	Telephone Interview Instrument
Public Health in Indian Country Capacity Scan Assessment (PHICCS)	0920-0879, 0920-0879, 0920-0879	PHICCS Instrument - Web Version ,   PHICCS Phone Administration of Instrument - Introduction ,   PHICCS Phone Administration of Instrument - Word Version
NOFO: Assessment of Language and Structure	none	NOFO Assessment
Determining the Landscape of QMSs for PHLs Performing NGS (LD)	0920-20PD	NGSQUAL-NA
The State of State Suicide Prevention: An Environmental Scan	0920-0879, 0920-0879, 0920-0879, 0920-0879	Suicide Prevention Web-based Survey - STT Suicide Prevention Coordinators ,   Suicide Prevention Web-based Survey - STT Suicide Prevention Grant Project Directors ,   Suicide Prevention Web-based Survey - Delegates ,   Suicide Prevention Telephone-based Survey - STT Suicide Prevention Coordinators
HIV Partner Services HIPEP Assessment	none, none	Partner Services Assessment - web ,   Partner Services Assessment - word
Assessment of the National Health Security Index for Public Health Preparedness	none, none	National Health Security Preparedness Index Assessment ,   National Health Security Preparedness Index Assessment - word
Medical Countermearsure Training Needs Assessment
PHEP Success Story Assessment	0920-0879, 0920-0879	PHEP Instrument Web ,   PHEP Instrument Word version
CDC Project Officer Support: SHD Officials Assessment	0920-0879	CDC Projct Oficer Effectiveness and Satisfaction Assessment: Instrument Guidance
Assessment of STLT Public Health Agencies to Guide the Update of CDC/ATSDR Cancer Cluster Guidelines	none, none	Assessment -word ,   Assessment - web
2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey	n/a	2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey
Prevention and Control of Shigellosis: A Needs Assessment of State and Local Health Departments	n/a	Telephone Interview guide
Qualitative Assessment of CDC-funded Local Health Dept Violence Prevention Efforts
NCCCP Program Improvement Assessment	none, none	NCCCP Assessment - word ,   NCCCP Assessment
RAWMILKPR - Unpasteurized Milk Outbreaks: An Assessment of the Legal Landscape, Outbreak Investigations, and Prevention at the State Leve	0920-0879	Unpasteurized Milk Outbreak Prevention Survy
NSSP BioSense Platform User Assessment: Functionality and Utility	n/a	The NSSP BioSense Platform User Assessment
Vector Surveillance and Control Assessment: Post Zika-Response and Tick Capacities (VECTOR-PZ)	n/a	2020 Vector Control Assessment
CDC Newborn Screening Quality Assurance Program – Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot	n/a, n/a	NSQPA Pilot SMA PT Data Reporting Form ,   NSQAP Pilot SMA PT Program Customer Feedback Form
Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction	0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879	STD Program Manager Referral Form ,   In-Person Interview Referral Form ,   Web-based Assessment Instrument ,   In-Person Interview Guide - Local STD Program Manager ,   In-Person Interview Guide - Local STD Program Coordinator ,   In-Person Interview Guide - Local Data Manager/Epidemiologist
STD Prevention and Control: Workplan Template Pilot	none, none	STD Applicant Workplan Template - 5 year plan ,   STD Applicant Workplan Template - 1 year plan
Environmental Health Workforce Current and Emerging Challenges Assessment	0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879	Recruitment Instrument - State Health Department EH Professional ,   Recruitment Instrument - Tribal Health Department EH Professional ,   Recruitment Instrument - Local Health Department EH Professional ,   Recruitment Instrument - Territorial Health Department EH Professional ,   Focus Group Facilitation Guide - STLT EH Professionals
EBP-PHPR	none, none	Assessment - Web version ,   Assessment - Word version
Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations (CMG-EVAL)	n/a, n/a	SurveyMonkey Survey for the Directors of Public Health Preparedness ,   Qualtrics Survey for Local Health Department Preparedness Coordinators
Community of Practice Member Satisfaction and Needs Assessment	none, none	Community of Practice Assessment - word ,   Community of Practice Assessment - web

---

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)	3,763,260	0	0	3,763,260	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:

---

Annual Cost to Federal Government: $87,055

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  No

---

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: 11/21/2017

---