Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Thirdparty_sitesecuritysurveyplan_Qualtrics_PHHS Block Grant Assessment.pdf	Supplementary Document	Uploaded 2019-01-17	Available
CDC_PRA_Determination_PHHS Block Grant Assessment.pdf	Supplementary Document	Uploaded 2019-01-17	Available
Attachment H - Non-Research Determination.pdf	Supplementary Document	Uploaded 2019-01-17	Available
Attachment G - Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2019-01-17	Available
Attachment C - PHHS Block Grant Measurement Framework Version 1.5.pdf	Supplementary Document	Uploaded 2019-01-17	Available
Attachment B - Authorizing Legislation Public Health Service Act _42 U.....pdf	Supplementary Document	Uploaded 2019-01-17	Available
Attachment A- List of PHHS Block Grant Grantees.docx	Supplementary Document	Uploaded 2019-01-17	Available
SSB_PHHS Block Grant Assessment_.docx	Supporting Statement B	Uploaded 2019-01-17	Available
SSA _PHHS Block Grant Assessment _revised_3.27.19.docx	Supporting Statement A	Uploaded 2019-03-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
234732	Preventive Health and Health Services Block Grant Assessment	Other-WORD	New

ICR Details

OMB Control No: 0920-1257	ICR Reference No: 201901-0920-003
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-18AVU
Title: Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/02/2019
	Date Received in OIRA: 02/08/2019
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time CDC will request approval to extend or revise the collection if CDC seeks to continue the information collection activity beyond the period or in the manner approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	36 Months From Approved
Responses	61	0	0
Time Burden (Hours)	46	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This data collection will assess select cross-cutting outputs and outcomes of the PHHS Block Grant and demonstrates the utility of the grant on a national level. Respondents include the 61 Block Grant grantees. Data will be collected using a web-based data collection instrument in fall 2019.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 45246	09/06/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 2522	02/07/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Preventive Health and Health Services Block Grant Assessment	0920-XXXX	Preventive Health and Health Services Block Grant Assessment

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	61	0	0	61	0	0
Annual Time Burden (Hours)	46	0	0	46	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a NEW collection request for a new OMB Control Number.

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Annual Cost to Federal Government: $25,394

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/08/2019

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