Information Collection

Ebp-phpr

IC 234422 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⚠️ Notice: This information collection may be referencing outdated material.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
EBP-PHPR	Form
Assessment - Web version Attachment C - Assessment Instrument Web Version.docx	Form
Assessment - Word version Attachment B - Assessment Instrument Word Version.docx	Form
EBP-PHPR-SSA.docx Supporting Statement A	IC Document
EBP-PHPR-SSB.docx Supporting Statement B	IC Document
Attachment A - Respondent Breakdown.docx List of Respondents	IC Document
Attachment D - ASTHO Advance Email.docx ASTHO Advance Email	IC Document
Attachment E - NACCHO Advance Email.docx NACCHO Advance Email	IC Document
Attachment F - NORC Invitation Email.docx NORC Invitation Email	IC Document
Attachment G - NORC Email Reminder 1.docx NORC Reminder Email	IC Document
Attachment H - NORC Email Reminder 2.docx NORC 2nd Reminder Email	IC Document
Attachment I - NORC Final Email Reminder.docx NORC Final Reminder Email	IC Document

IC Title:

EBP-PHPR

Agency IC Tracking Number:

0920-0879-19GY

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	Assessment - Web version	Attachment C - Assessment Instrument Web Version.docx		Yes	Yes	Fillable Fileable
Form	none	Assessment - Word version	Attachment B - Assessment Instrument Word Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 562

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	562	562
Annual IC Time Burden (Hours)	328	328
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	EBP-PHPR-SSA.docx	12/06/2018
Supporting Statement B	EBP-PHPR-SSB.docx	12/06/2018
List of Respondents	Attachment A - Respondent Breakdown.docx	12/06/2018
ASTHO Advance Email	Attachment D - ASTHO Advance Email.docx	12/06/2018
NACCHO Advance Email	Attachment E - NACCHO Advance Email.docx	12/06/2018
NORC Invitation Email	Attachment F - NORC Invitation Email.docx	12/06/2018
NORC Reminder Email	Attachment G - NORC Email Reminder 1.docx	12/06/2018
NORC 2nd Reminder Email	Attachment H - NORC Email Reminder 2.docx	12/06/2018
NORC Final Reminder Email	Attachment I - NORC Final Email Reminder.docx	12/06/2018

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