Information Collection

PHEP Success Story Assessment

IC 233545 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⚠️ Notice: This information collection may be referencing outdated material.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 PHEP Success Story Assessment	Form and Instruction
0920-0879 PHEP Instrument Web Attachment C - PHEP Insturment - Web Version.docx	Form and Instruction
0920-0879 PHEP Instrument Word version Attachment B - PHEP Instrument- Word Version.docx	Form and Instruction
Attachment A - Respondent Breakdown.docx Respondent Breakdown	IC Document
Attachment D - Invitation Email.docx Invitation Email	IC Document
Attachment E - Reminder Email.docx Reminder Email	IC Document
PHEP-EVAL-SSA.docx SSA	IC Document
PHEP-EVAL-SSB.docx SSB	IC Document

IC Title:

PHEP Success Story Assessment

Agency IC Tracking Number:

0920-0879-19AY

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	PHEP Instrument Web	Attachment C - PHEP Insturment - Web Version.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	PHEP Instrument Word version	Attachment B - PHEP Instrument- Word Version.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 62

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	62	62
Annual IC Time Burden (Hours)	5	5
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	10/16/2018
Invitation Email	Attachment D - Invitation Email.docx	10/16/2018
Reminder Email	Attachment E - Reminder Email.docx	10/16/2018
SSA	PHEP-EVAL-SSA.docx	10/16/2018
SSB	PHEP-EVAL-SSB.docx	10/16/2018

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