Information Collection

STD Prevention and Control: Workplan Template Pilot

IC 231342 under ICR 201711-0920-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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
STD Applicant Workplan Template - 5 year plan STD Prevention and Control: Workplan Template Pilot	Form
STD Applicant Workplan Template - 1 year plan STD Prevention and Control: Workplan Template Pilot	Form
STD Applicant Workplan Template - 5 year plan Attachment C - Instrument 1- STD Applicant Work Plan Template_5 Year Pla....xlsm	Form
STD Applicant Workplan Template - 1 year plan Attachment D - Instrument 2- STD Applicant Work Plan Template_1 Year Pla....xlsm	Form
Attachment A - List of Eligible Applicants to PS19-1901 STD PCHD.DOCX List of Applicants	IC Document
Attachment B - PS19-1901 STD PCHD Fact Sheet.docx Fast Sheet	IC Document
Attachment E- Notification Email.docx Notification Email	IC Document
Attachment F- Reminder Email.docx Reminder Email	IC Document
Attachment G- Final Reminder Email.docx Final Reminder Email	IC Document
STD-WKPLN-SSA.docx Supporting Statement A	IC Document
STD-WKPLN-SSB.docx Supporting Statement B	IC Document

IC Title:

STD Prevention and Control: Workplan Template Pilot

Agency IC Tracking Number:

0920-0879-18AEI

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
Form	none	STD Applicant Workplan Template - 5 year plan	Attachment C - Instrument 1- STD Applicant Work Plan Template_5 Year Pla....xlsm		Yes	Yes	Fillable Fileable
Form	none	STD Applicant Workplan Template - 1 year plan	Attachment D - Instrument 2- STD Applicant Work Plan Template_1 Year Pla....xlsm		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

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	59	59
Annual IC Time Burden (Hours)	272	272
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
List of Applicants	Attachment A - List of Eligible Applicants to PS19-1901 STD PCHD.DOCX	05/07/2018
Fast Sheet	Attachment B - PS19-1901 STD PCHD Fact Sheet.docx	05/07/2018
Notification Email	Attachment E- Notification Email.docx	05/07/2018
Reminder Email	Attachment F- Reminder Email.docx	05/07/2018
Final Reminder Email	Attachment G- Final Reminder Email.docx	05/07/2018
Supporting Statement A	STD-WKPLN-SSA.docx	05/07/2018
Supporting Statement B	STD-WKPLN-SSB.docx	05/07/2018

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