STD Prevention and Control: Workplan Template Pilot

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

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.