Information Collection

Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction

IC 231786 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0879 Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction	Form and Instruction
0920-0879 STD Program Manager Referral Form Attachment B- STD Program Manager Referral Form.docx	Form and Instruction
0920-0879 In-Person Interview Referral Form Attachment C- In-person Interview Referral Form.docx	Form and Instruction
0920-0879 Web-based Assessment Instrument Attachment E- EPP Web-based Instrument-Web Version.pdf	Form and Instruction
0920-0879 In-Person Interview Guide - Local STD Program Manager Attachment F- EPP- In-Person Interview Guide STD Program Manager and STD Program Coordinator.docx	Form and Instruction
0920-0879 In-Person Interview Guide - Local STD Program Coordinato Attachment F- EPP- In-Person Interview Guide STD Program Manager and STD Program Coordinator.docx	Form and Instruction
0920-0879 In-Person Interview Guide - Local Data Manager/Epidemiol Attachment G- EPP- In-Person Interview Guide Data Manager.docx	Form and Instruction
Attachment H- EPP Overview - Assessment of Partnerships Impacting STD Outcomes 1pg format.docx Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction: Project Overview	IC Document
Attachment A-Respondent Breakdown.docx Respondent Breakdown	IC Document
Attachment I- Web-based Assessment Invitation Email.docx Web-based Assessment - Invitation Email	IC Document
Attachment J- Web-based Assessment Reminder Email 1.docx Web-based Assessment - Reminder Email 1	IC Document
Attachment K- Web-based Assessment Reminder Email 2.docx Web-based Assessment - Reminder Email 2	IC Document
Attachment L-In-Person Interview Invitation Email.docx In-Person Interview Invitation Email	IC Document
Attachment M- In-Person Interview Reminder Email.docx In-Person Interview Reminder Email	IC Document
EPP-SSA.docx Supporting Statement A	IC Document
EPP-SSB.docx Supporting Statement B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction

Agency IC Tracking Number:

0920-0879-18ANY

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 and Instruction	0920-0879	STD Program Manager Referral Form	Attachment B- STD Program Manager Referral Form.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	In-Person Interview Referral Form	Attachment C- In-person Interview Referral Form.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	Web-based Assessment Instrument	Attachment E- EPP Web-based Instrument-Web Version.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	In-Person Interview Guide - Local STD Program Manager	Attachment F- EPP- In-Person Interview Guide STD Program Manager and STD Program Coordinator.docx	NA	No		Paper Only
Form and Instruction	0920-0879	In-Person Interview Guide - Local STD Program Coordinator	Attachment F- EPP- In-Person Interview Guide STD Program Manager and STD Program Coordinator.docx	NA	No		Paper Only
Form and Instruction	0920-0879	In-Person Interview Guide - Local Data Manager/Epidemiologist	Attachment G- EPP- In-Person Interview Guide Data Manager.docx	NA	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 184

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	184	184
Annual IC Time Burden (Hours)	132	132
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Assessment of Partnerships Impacting STD Outcomes in Areas of Service Reduction: Project Overview	Attachment H- EPP Overview - Assessment of Partnerships Impacting STD Outcomes 1pg format.docx	06/14/2018
Respondent Breakdown	Attachment A-Respondent Breakdown.docx	06/14/2018
Web-based Assessment - Invitation Email	Attachment I- Web-based Assessment Invitation Email.docx	06/14/2018
Web-based Assessment - Reminder Email 1	Attachment J- Web-based Assessment Reminder Email 1.docx	06/14/2018
Web-based Assessment - Reminder Email 2	Attachment K- Web-based Assessment Reminder Email 2.docx	06/14/2018
In-Person Interview Invitation Email	Attachment L-In-Person Interview Invitation Email.docx	06/14/2018
In-Person Interview Reminder Email	Attachment M- In-Person Interview Reminder Email.docx	06/14/2018
Supporting Statement A	EPP-SSA.docx	06/14/2018
Supporting Statement B	EPP-SSB.docx	06/14/2018

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