Ebp-phpr

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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

IC Title:	EBP-PHPR	Agency IC Tracking Number:	0920-0879-19GY

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	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 %

	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

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.