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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Feedback Form	Form and Instruction	New	Available
Data Reporting Page	Form and Instruction	New	Available
Community of Practice Assessment - web	Form	New	Available
Community of Practice Assessment - word	Form	New	Available
2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey	Form and Instruction	New	Available
Assessment - web	Form	New	Available
Assessment -word	Form	New	Available
Form 0920-20PX Colo-rectal Cancer Control Program Survey	Form and Instruction	New	Available
NCCCP Assessment	Form	New	Available
NCCCP Assessment - word	Form	New	Available
National Health Security Preparedness Index Assessment - word	Form	New	Available
National Health Security Preparedness Index Assessment	Form	New	Available
NSQAP Pilot SMA PT Program Customer Feedback Form	Form and Instruction	New	Available
NSQPA Pilot SMA PT Data Reporting Form	Form and Instruction	New	Available
2020 Vector Control Assessment	Form and Instruction	New	Available
Form 0920-20PD NGSQUAL-NA	Form and Instruction	New	Available
Partner Services Assessment - word	Form	New	Available
Partner Services Assessment - web	Form	New	Repair queued
Form 0920-0879 Unpasteurized Milk Outbreak Prevention Survy	Form and Instruction	New	Available
Form 0920-0879 CDC Projct Oficer Effectiveness and Satisfaction Assessment: Instrument Guidance	Form and Instruction	New	Available
Form 0920-0879 Interview Guide	Form and Instruction	New	Available
Qualtrics Survey for Local Health Department Preparedness Coordinators	Form and Instruction	New	Available
SurveyMonkey Survey for the Directors of Public Health Preparedness	Form and Instruction	New	Available
The NSSP BioSense Platform User Assessment	Form and Instruction	New	Available
NOFO Assessment	Form	New	Available
Form 0920-0879 Focus Group Facilitation Guide	Form and Instruction	New	Available
Form 0920-0879 Web-Based Assessment	Form and Instruction	New	Available
Assessment - Word version	Form	New	Available
Assessment - Web version	Form	New	Available
Telephone Interview Instrument	Form and Instruction	New	Available
Telephone Interview Guide for State Oral Health Staff	Form and Instruction	New	Available
Online Survey (screen captures)	Form and Instruction	New	Available
Form 0920-0879 PHEP Instrument Word version	Form and Instruction	New	Available
Form 0920-0879 PHEP Instrument Web	Form and Instruction	New	Available
Form 0920-0879 PHICCS Phone Administration of Instrument - Word Version	Form and Instruction	New	Available
Form 0920-0879 PHICCS Phone Administration of Instrument - Introduction	Form and Instruction	New	Available
Form 0920-0879 PHICCS Instrument - Web Version	Form and Instruction	New	Repair queued
Form 0920-0879 DROUGHT Preparedness and Response Assessment Tool (DEMO)	Form and Instruction	New	Available
Form 0920-0879 In-Person Interview Guide - Local Data Manager/Epidemiologist	Form and Instruction	New	Available
Form 0920-0879 In-Person Interview Guide - Local STD Program Coordinator	Form and Instruction	New	Available
Form 0920-0879 In-Person Interview Guide - Local STD Program Manager	Form and Instruction	New	Available
Form 0920-0879 Web-based Assessment Instrument	Form and Instruction	New	Available
Form 0920-0879 In-Person Interview Referral Form	Form and Instruction	New	Available
Form 0920-0879 STD Program Manager Referral Form	Form and Instruction	New	Available
Form 0920-0879 Focus Group Facilitation Guide - STLT EH Professionals	Form and Instruction	New	Available
Form 0920-0879 Recruitment Instrument - Territorial Health Department EH Professional	Form and Instruction	New	Repair queued
Form 0920-0879 Recruitment Instrument - Local Health Department EH Professional	Form and Instruction	New	Available
Form 0920-0879 Recruitment Instrument - Tribal Health Department EH Professional	Form and Instruction	New	Available
Form 0920-0879 Recruitment Instrument - State Health Department EH Professional	Form and Instruction	New	Available
Form 0920-0879 Suicide Prevention Telephone-based Survey - STT Suicide Prevention Coordinators	Form and Instruction	New	Available
Form 0920-0879 Suicide Prevention Web-based Survey - Delegates	Form and Instruction	New	Available
Form 0920-0879 Suicide Prevention Web-based Survey - STT Suicide Prevention Grant Project Directors	Form and Instruction	New	Available
Form 0920-0879 Suicide Prevention Web-based Survey - STT Suicide Prevention Coordinators	Form and Instruction	New	Available
Telephone Interview guide	Form and Instruction	New	Available
STD Applicant Workplan Template - 1 year plan	Form	New	Available
STD Applicant Workplan Template - 5 year plan	Form	New	Available
Form 0920-0879 Online Survey Instrument_Web version	Form and Instruction	New	Available
Form 0920-0879 Telephone Interview Guide	Form and Instruction	New	Available
Community of Practice - web	Form	New	Available
Community of Practice Assessment - word	Form	New	Available
Attachment B_Approved GenICs under 0920-0879 updated 112017.docx	Supplementary Document	Uploaded 2017-11-20	Repair queued
Statement B for 0920-0879 ICR updated 112017.docx	Supporting Statement B	Uploaded 2017-11-20	Available
Statement A for 0920-0879 ICR_updated 112017.docx	Supporting Statement A	Uploaded 2017-11-20	Available
Attachment A Public Health Service Act.doc	Supplementary Document	Uploaded 2017-11-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
244433	Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot	Form and Instruction	New	Feedback Form
244433	Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot	Form and Instruction	New	Data Reporting Page
243890	Community of Practice Member Satisfaction and Needs Assessment	Form	New	Community of Practice Assessment - web
243890	Community of Practice Member Satisfaction and Needs Assessment	Form	New	Community of Practice Assessment - word
243827	2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey	Form and Instruction	New	2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey
243827	2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey	Other-WORD version of survey to facilitate review of content	New
242670	Assessment of STLT Public Health Agencies to Guide the Update of CDC/ATSDR Cancer Cluster Guidelines	Form	New	Assessment - web
242670	Assessment of STLT Public Health Agencies to Guide the Update of CDC/ATSDR Cancer Cluster Guidelines	Form	New	Assessment -word
242670	Assessment of STLT Public Health Agencies to Guide the Update of CDC/ATSDR Cancer Cluster Guidelines	Other-Focus group guide	New
242474	Assessment of Colorectal Cancer Control Program Implementation at Health System Clinic Sites	Form and Instruction	New	Colo-rectal Cancer Control Program Survey
242474	Assessment of Colorectal Cancer Control Program Implementation at Health System Clinic Sites	Other-Web Version	New
242393	NCCCP Program Improvement Assessment	Form	New	NCCCP Assessment
242393	NCCCP Program Improvement Assessment	Form	New	NCCCP Assessment - word
242255	Assessment of the National Health Security Index for Public Health Preparedness	Form	New	National Health Security Preparedness Index Assessment - word
242255	Assessment of the National Health Security Index for Public Health Preparedness	Form	New	National Health Security Preparedness Index Assessment
242255	Assessment of the National Health Security Index for Public Health Preparedness	Other-Interview guide	New
242252	CDC Newborn Screening Quality Assurance Program – Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot	Form and Instruction	New	NSQAP Pilot SMA PT Program Customer Feedback Form
242252	CDC Newborn Screening Quality Assurance Program – Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot	Form and Instruction	New	NSQPA Pilot SMA PT Data Reporting Form
242191	Vector Surveillance and Control Assessment: Post Zika-Response and Tick Capacities (VECTOR-PZ)	Form and Instruction	New	2020 Vector Control Assessment
242191	Vector Surveillance and Control Assessment: Post Zika-Response and Tick Capacities (VECTOR-PZ)	Other-WORD version of survey content to facilitate review	New
242187	Determining the Landscape of QMSs for PHLs Performing NGS (LD)	Form and Instruction	New	NGSQUAL-NA
241449	HIV Partner Services HIPEP Assessment	Form	New	Partner Services Assessment - word
241449	HIV Partner Services HIPEP Assessment	Form	New	Partner Services Assessment - web
240830	RAWMILKPR - Unpasteurized Milk Outbreaks: An Assessment of the Legal Landscape, Outbreak Investigations, and Prevention at the State Leve	Form and Instruction	New	Unpasteurized Milk Outbreak Prevention Survy
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	Form and Instruction	New	CDC Projct Oficer Effectiveness and Satisfaction Assessment: Instrument Guidance
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	Interview Guide
236347	Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations (CMG-EVAL)	Form and Instruction	New	Qualtrics Survey for Local Health Department Preparedness Coordinators
236347	Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations (CMG-EVAL)	Form and Instruction	New	SurveyMonkey Survey for the Directors of Public Health Preparedness
236347	Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations (CMG-EVAL)	Other-Word version of survey to facilitate review of content	New
236064	NSSP BioSense Platform User Assessment: Functionality and Utility	Form and Instruction	New	The NSSP BioSense Platform User Assessment
236064	NSSP BioSense Platform User Assessment: Functionality and Utility	Other-This is a Word version of the instrument to facilitate rev	New
235662	NOFO: Assessment of Language and Structure	Form	New	NOFO Assessment
235662	NOFO: Assessment of Language and Structure	Other-Interview Guide	New
234911	SLPHERLT	Form and Instruction	New	Focus Group Facilitation Guide
234911	SLPHERLT	Form and Instruction	New	Web-Based Assessment
234422	EBP-PHPR	Form	New	Assessment - Word version
234422	EBP-PHPR	Form	New	Assessment - Web version
234047	State Oral Health and Chronic Disease Programs Integration Assessment	Form and Instruction	New	Telephone Interview Instrument
233547	State Oral Health Program Assessment	Form and Instruction	New	Telephone Interview Guide for State Oral Health Staff
233547	State Oral Health Program Assessment	Form and Instruction	New	Online Survey (screen captures)
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	PHEP Instrument Word version
233545	PHEP Success Story Assessment	Form and Instruction	New	PHEP Instrument Web
232932	Public Health in Indian Country Capacity Scan Assessment (PHICCS)	Form and Instruction	New	PHICCS Phone Administration of Instrument - Word Version
232932	Public Health in Indian Country Capacity Scan Assessment (PHICCS)	Form and Instruction	New	PHICCS Phone Administration of Instrument - Introduction
232932	Public Health in Indian Country Capacity Scan Assessment (PHICCS)	Form and Instruction	New	PHICCS Instrument - Web Version
232671	DROUGHT-IC	Form and Instruction	New	DROUGHT Preparedness and Response Assessment Tool (DEMO)
232671	DROUGHT-IC	Other-WORD	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	In-Person Interview Guide - Local Data Manager/Epidemiologist
231786	Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction	Form and Instruction	New	In-Person Interview Guide - Local STD Program Coordinator
231786	Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction	Form and Instruction	New	In-Person Interview Guide - Local STD Program Manager
231786	Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction	Form and Instruction	New	Web-based Assessment Instrument
231786	Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction	Form and Instruction	New	In-Person Interview Referral Form
231786	Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction	Form and Instruction	New	STD Program Manager Referral Form
231592	Environmental Health Workforce Current and Emerging Challenges Assessment	Form and Instruction	New	Focus Group Facilitation Guide - STLT EH Professionals
231592	Environmental Health Workforce Current and Emerging Challenges Assessment	Form and Instruction	New	Recruitment Instrument - Territorial Health Department EH Professional
231592	Environmental Health Workforce Current and Emerging Challenges Assessment	Form and Instruction	New	Recruitment Instrument - Local Health Department EH Professional
231592	Environmental Health Workforce Current and Emerging Challenges Assessment	Form and Instruction	New	Recruitment Instrument - Tribal Health Department EH Professional
231592	Environmental Health Workforce Current and Emerging Challenges Assessment	Form and Instruction	New	Recruitment Instrument - State Health Department EH Professional
231591	The State of State Suicide Prevention: An Environmental Scan	Form and Instruction	New	Suicide Prevention Telephone-based Survey - STT Suicide Prevention Coordinators
231591	The State of State Suicide Prevention: An Environmental Scan	Form and Instruction	New	Suicide Prevention Web-based Survey - Delegates
231591	The State of State Suicide Prevention: An Environmental Scan	Form and Instruction	New	Suicide Prevention Web-based Survey - STT Suicide Prevention Grant Project Directors
231591	The State of State Suicide Prevention: An Environmental Scan	Form and Instruction	New	Suicide Prevention Web-based Survey - STT Suicide Prevention Coordinators
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	Telephone Interview guide
231342	STD Prevention and Control: Workplan Template Pilot	Form	New	STD Applicant Workplan Template - 1 year plan
231342	STD Prevention and Control: Workplan Template Pilot	Form	New	STD Applicant Workplan Template - 5 year plan
231324	Public Health Ethics Activities at State and Local Health Departments: Current Status and Challenges	Form and Instruction	New	Online Survey Instrument_Web version
231324	Public Health Ethics Activities at State and Local Health Departments: Current Status and Challenges	Form and Instruction	New	Telephone Interview Guide
231188	National Syndromic Surveillance Program Community of Practice Assessment	Form	New	Community of Practice - web
231188	National Syndromic Surveillance Program Community of Practice Assessment	Form	New	Community of Practice Assessment - word

ICR Details

OMB Control No: 0920-0879	ICR Reference No: 201711-0920-012
Status: Historical 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
Retrieve Notice of Action (NOA)	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).

table that charts list comparision

	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

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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.

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

Citations for New Statutory Requirements: None

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

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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

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

table that charts list of burden

IC Title	Form No.	Form Name
2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey	n/a	2020 Carbapenem Resistance Veterinary Diagnostic Laboratory Survey
Assessment of Colorectal Cancer Control Program Implementation at Health System Clinic Sites	0920-20PX	Colo-rectal Cancer Control Program Survey
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
Assessment of STLT Public Health Agencies to Guide the Update of CDC/ATSDR Cancer Cluster Guidelines	none, none	Assessment -word ,   Assessment - web
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
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
CDC Project Officer Support: SHD Officials Assessment	0920-0879	CDC Projct Oficer Effectiveness and Satisfaction Assessment: Instrument Guidance
Community of Practice Member Satisfaction and Needs Assessment	none, none	Community of Practice Assessment - word ,   Community of Practice Assessment - web
DROUGHT-IC	0920-0879	DROUGHT Preparedness and Response Assessment Tool (DEMO)
Determining the Landscape of QMSs for PHLs Performing NGS (LD)	0920-20PD	NGSQUAL-NA
EBP-PHPR	none, none	Assessment - Web version ,   Assessment - Word version
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
HIV Partner Services HIPEP Assessment	none, none	Partner Services Assessment - web ,   Partner Services Assessment - word
Medical Countermearsure Training Needs Assessment
NCCCP Program Improvement Assessment	none, none	NCCCP Assessment - word ,   NCCCP Assessment
NOFO: Assessment of Language and Structure	none	NOFO Assessment
NSSP BioSense Platform User Assessment: Functionality and Utility	n/a	The NSSP BioSense Platform User Assessment
National Syndromic Surveillance Program Community of Practice Assessment	none, none	Community of Practice Assessment - word ,   Community of Practice - web
PHEP Success Story Assessment	0920-0879, 0920-0879	PHEP Instrument Web ,   PHEP Instrument 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
Pre-Hospital Stroke Systems of Care: Emergency Medical Service System (EMSS) Implementation Assessment	0920-0879	Interview Guide
Prevention and Control of Shigellosis: A Needs Assessment of State and Local Health Departments	n/a	Telephone Interview guide
Public Health Ethics Activities at State and Local Health Departments: Current Status and Challenges	0920-0879, 0920-0879	Telephone Interview Guide ,   Online Survey Instrument_Web version
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
Qualitative Assessment of CDC-funded Local Health Dept Violence Prevention Efforts
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
SLPHERLT	0920-0879, 0920-0879	Web-Based Assessment ,   Focus Group Facilitation Guide
STD Prevention and Control: Workplan Template Pilot	none, none	STD Applicant Workplan Template - 5 year plan ,   STD Applicant Workplan Template - 1 year plan
Spinal Muscular Atrophy (SMA) Proficiency Testing (PT) Pilot	none, none	Data Reporting Page ,   Feedback Form
State Oral Health Program Assessment	n/a, n/a	Online Survey (screen captures) ,   Telephone Interview Guide for State Oral Health Staff
State Oral Health and Chronic Disease Programs Integration Assessment	n/a	Telephone Interview Instrument
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
Vector Surveillance and Control Assessment: Post Zika-Response and Tick Capacities (VECTOR-PZ)	n/a	2020 Vector Control Assessment

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ICR Summary of Burden

table that charts list 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:

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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

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Common Form ICR:  No

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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

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