Information Collection

Slpherlt

IC 234911 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⚠️ Notice: This information collection may be referencing outdated material.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 SLPHERLT	Form and Instruction
0920-0879 Web-Based Assessment Attachment C - Web-Based Assessment Word Version_30Jan19.docx	Form and Instruction
0920-0879 Focus Group Facilitation Guide Attachment E - Focus Group Facilitation Guide Word Version_30Jan19.docx	Form and Instruction
SLPHERLT-SSA final.docx SSA	IC Document
SLPHERLT-SSB.docx SSB	IC Document
Attachment A - Respondent Universe_30Jan19.docx Respondent Universe	IC Document
Attachment B - Sample of Respondents_30Jan19.docx Sample of Respondents	IC Document
Attachment D - Web-Based Assessment Web Version_30Jan19.docx Web-Based Assessment Web Version	IC Document
Attachment F - Web-Based Assessment PHEP Director Invitation Email Word Version_30Jan19.docx PHEP Director Invitation Email	IC Document
Attachment G - Web-Based Assessment Local Invitation Email Word Version_30Jan19.docx Local Invitation Email	IC Document
Attachment H - Web-Based Assessment One-Page Factsheet_30Jan19.docx Web One-Page Factsheet	IC Document
Attachment I - Web-Based Assessment PHEP Director Reminder Email Word Version_30Jan19.docx PHEP Director Reminder Email	IC Document
Attachment J - Web-Based Assessment Local Reminder Email Word Version_30Jan19.docx Local Reminder Email	IC Document
Attachment K - Generic Focus Group Invitation Email, Word Version_1Feb19.docx Generic Focus Group Invitation Email	IC Document
Attachment L - Focus Group One-Page Factsheet_30Jan19.docx Focus Group One-Page Factsheet	IC Document
Attachment M - Focus Group Enrollment and Waiver Form_30Jan19.docx Focus Group Enrollment and Waiver Form	IC Document
Attachment N - Focus Group Participation Confirmation Email_30Jan19.docx Focus Group Participation Confirmation Email	IC Document
Attachment O - Focus Group Reminder Call Script, Word Version_30Jan19.docx Focus Group Reminder Call Script	IC Document
Attachment P - Focus Group Conduct Reminder Email, Word Version_30Jan19.docx Focus Group Conduct Reminder Email	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

SLPHERLT

Agency IC Tracking Number:

0920-0879-19TH

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	Web-Based Assessment	Attachment C - Web-Based Assessment Word Version_30Jan19.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	Focus Group Facilitation Guide	Attachment E - Focus Group Facilitation Guide Word Version_30Jan19.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: 762

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 96 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	762	762
Annual IC Time Burden (Hours)	283	283
Annual IC Cost Burden (Dollars)	12,217	12,217

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA	SLPHERLT-SSA final.docx	02/12/2019
SSB	SLPHERLT-SSB.docx	02/12/2019
Respondent Universe	Attachment A - Respondent Universe_30Jan19.docx	02/12/2019
Sample of Respondents	Attachment B - Sample of Respondents_30Jan19.docx	02/12/2019
Web-Based Assessment Web Version	Attachment D - Web-Based Assessment Web Version_30Jan19.docx	02/12/2019
PHEP Director Invitation Email	Attachment F - Web-Based Assessment PHEP Director Invitation Email Word Version_30Jan19.docx	02/12/2019
Local Invitation Email	Attachment G - Web-Based Assessment Local Invitation Email Word Version_30Jan19.docx	02/12/2019
Web One-Page Factsheet	Attachment H - Web-Based Assessment One-Page Factsheet_30Jan19.docx	02/12/2019
PHEP Director Reminder Email	Attachment I - Web-Based Assessment PHEP Director Reminder Email Word Version_30Jan19.docx	02/12/2019
Local Reminder Email	Attachment J - Web-Based Assessment Local Reminder Email Word Version_30Jan19.docx	02/12/2019
Generic Focus Group Invitation Email	Attachment K - Generic Focus Group Invitation Email, Word Version_1Feb19.docx	02/12/2019
Focus Group One-Page Factsheet	Attachment L - Focus Group One-Page Factsheet_30Jan19.docx	02/12/2019
Focus Group Enrollment and Waiver Form	Attachment M - Focus Group Enrollment and Waiver Form_30Jan19.docx	02/12/2019
Focus Group Participation Confirmation Email	Attachment N - Focus Group Participation Confirmation Email_30Jan19.docx	02/12/2019
Focus Group Reminder Call Script	Attachment O - Focus Group Reminder Call Script, Word Version_30Jan19.docx	02/12/2019
Focus Group Conduct Reminder Email	Attachment P - Focus Group Conduct Reminder Email, Word Version_30Jan19.docx	02/12/2019

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