Information Collection

Public Health in Indian Country Capacity Scan Assessment (PHICCS)

IC 232932 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⚠️ Notice: This information collection may be referencing outdated material.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 Public Health in Indian Country Capacity Scan Assessment (PHICCS)	Form and Instruction
0920-0879 PHICCS Instrument - Web Version Attachment C - PHICCS Instrument (Web version).docx	Form and Instruction
0920-0879 PHICCS Phone Administration of Instrument - Introduction Attachment E - PHICCS Phone Administration of Instrument_Introductory Language.docx	Form and Instruction
0920-0879 PHICCS Phone Administration of Instrument - Word Version Attachment D - PHICCS Instrument (Word version)_revised.docx	Form and Instruction
Attachment A - Respondent Breakdown.docx Respondent Breakdown	IC Document
Attachment B - 2010 NIHB Tribal Public Health Profile.pdf 2010 NIHB Tribal Public Health Profile	IC Document
Attachment F - ASTHO Profile Volume Three.pdf ASTHO Profile	IC Document
Attachment G - NACCHO 2016 Report.pdf NACCHO - 2016 Report	IC Document
Attachment I - PHICCS Email Invitation-revised.docx PHICCS - Email Invitation	IC Document
Attachment J - PHICCS Email Reminder-revised.docx PHICCS - Email Reminder	IC Document
Attachment K - PHICCS Phone Reminder-revised.docx PHICCDS - Phone Reminder	IC Document
Attachment L - PHICCS Pre-Launch Webinar Email.docx PHICCS - Pre-Launch Webinar Email	IC Document
Attachment M - PHICCS Pre-Launch Webinar.docx PHICCS - Pre-Launch Webinar	IC Document
Attachment H - IHS Email of Support.docx IHS - Email of Support	IC Document
PHICCS-SSA-071318-Revised - IHS Comments - 8-31-2018.docx Supporting Statement A	IC Document
PHICCS-SSB-revised.docx Supporting Statement B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Public Health in Indian Country Capacity Scan Assessment (PHICCS)

Agency IC Tracking Number:

0920-0879-18AZR

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	PHICCS Instrument - Web Version	Attachment C - PHICCS Instrument (Web version).docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	PHICCS Phone Administration of Instrument - Introduction	Attachment E - PHICCS Phone Administration of Instrument_Introductory Language.docx	NA	No		Fillable Fileable
Form and Instruction	0920-0879	PHICCS Phone Administration of Instrument - Word Version	Attachment D - PHICCS Instrument (Word version)_revised.docx	NA	No		Fillable Fileable

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: 261

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 65 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	261	261
Annual IC Time Burden (Hours)	261	261
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Respondent Breakdown	Attachment A - Respondent Breakdown.docx	09/07/2018
2010 NIHB Tribal Public Health Profile	Attachment B - 2010 NIHB Tribal Public Health Profile.pdf	09/07/2018
ASTHO Profile	Attachment F - ASTHO Profile Volume Three.pdf	09/07/2018
NACCHO - 2016 Report	Attachment G - NACCHO 2016 Report.pdf	09/07/2018
PHICCS - Email Invitation	Attachment I - PHICCS Email Invitation-revised.docx	09/07/2018
PHICCS - Email Reminder	Attachment J - PHICCS Email Reminder-revised.docx	09/07/2018
PHICCDS - Phone Reminder	Attachment K - PHICCS Phone Reminder-revised.docx	09/07/2018
PHICCS - Pre-Launch Webinar Email	Attachment L - PHICCS Pre-Launch Webinar Email.docx	09/07/2018
PHICCS - Pre-Launch Webinar	Attachment M - PHICCS Pre-Launch Webinar.docx	09/07/2018
IHS - Email of Support	Attachment H - IHS Email of Support.docx	09/07/2018
Supporting Statement A	PHICCS-SSA-071318-Revised - IHS Comments - 8-31-2018.docx	09/07/2018
Supporting Statement B	PHICCS-SSB-revised.docx	09/07/2018

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