CDC_PRA Determination Form

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PAPERWORK REDUCTION ACT DETERMINATION FORM
AUTHORITY: The Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520), 5 Code of Federal Regulations (CFR) Part 1320
PRINCIPAL PURPOSES: To determine applicability of Centers for Disease Control and Prevention (CDC) proposed projects for Paperwork Reduction Act
(PRA) compliance. Proper completion of this form will prevent both illegal information collections and PRA violations.
ROUTINE USES: Information is disclosed to the Information Collection Review Office (ICRO) for auditing and quality assurance purposes.
MANDATORY DISCLOSURE: Failure to provide complete information and the necessary supporting documents may delay proposed project activities.
As a Federal Government agency, CDC is subject to the PRA. The information on this form is required to make a project’s PRA applicability
determination. This form (pages 1 and 2) must be completed by the Center, Institute, Office (CIO) PRA Contact. A copy of the related supporting
documents that identify all proposed project collection of information (reporting), retention of information (recordkeeping), and disclosure of
information (disclosing) activities must accompany this form upon submittal to ICRO via [email protected].
I. Center, Institute, Office (CIO) Information
CIO Abbreviation: OSTLTS
CIO PRA Contact: Name (Last, First)

CDC E-mail:

Phone No.:

Wigington, Corinne
Project Officer/Investigator/Point of Contact: Name (Last, First)

[email protected]
CDC E-mail:

404-574-3497
Phone No.:

Frazier, Cassandra
[email protected]
Project Title: Preventive Health and Health Services (PHHS) Block Grant Assessment
Funding Mechanism Type: ☐ Contract
Announcement #: 93.991

☐ Cooperative Agreement

☐ Grant

404-498-0581

☐ Task/Purchase Order

☐ Other

II. Determination Conditions
To determine a project’s PRA applicability, record responses to the below conditions (Please Check).
1. Does the proposed activity obtain, cause to be obtained, solicit, or require the disclosure to CDC/ATSDR or a third party information by or for
CDC/ATSDR? In other words, will CDC/ATSDR require the collection, retention, or disclosure of information? ☐ Yes ☐ No
2. Does the proposed collection entail identical questions posed to, or identical reporting, recordkeeping, or
☐ Yes ☐ No
disclosure requirements imposed on or requesting the same information from ten (10) or more persons?
☐ Yes ☐ No
3. Is the collection of information conducted by CDC/ATSDR (will CDC/ATSDR collect the information)?
☐
Yes ☐ No
4. Is the collection of information sponsored by CDC/ATSDR?
5. If applicable, is this collection of information waived by the
National Childhood Vaccine Injury Act [Public Law 99-660, section 321-Title III]?
☐ Yes ☐ No
III. CIO Determination Decision (Please Check)
☐
OMB/PRA Clearance Required, as proposed activity constitutes a collection of information - (If “Yes” response provided for items 1-2 and for
either item 3 or 4 in the previous section)
☐
OMB/PRA Clearance Not Required – Per 5. C.F.R. 1320.3(h), the following PRA exemption/exclusion category applies to this collection of
information:
OMB/PRA Clearance Not Required – An active Information Collection Request for this activity has already been approved by OMB.
Title:
OMB Number:
Expiration Date:
☐
OMB/PRA Clearance Not Required – (If a “No” response provided for items 1 or 2 or if a “No” response for items 3 and 4 in the previous section)
☐
OMB/PRA Clearance Not Required – The PRA requirement waived by the National Childhood Vaccine Injury Act [Public Law 99-660, section 321Title III].
IV. Proposed Project Dates: 09/30/2018
to 09/29/2021
☐

V. Proposed Project Activities
If applicable, indicate the type of Information Collection Instrument/Activity proposed for use (Check all that apply):
☐ Mail-back Questionnaire ☐ On-site Questionnaire ☐ Personal Interview ☐ Telephone Survey ☐ Testing/Assessment Form
☐ Web-based Survey ☐ Focus Groups ☐ Record Abstractions ☐ Performance Report ☐ Evaluation ☐ Observation
☐ Application ☐ Comment Card ☐ Discussion Group ☐ Eligibility Form ☐ Audit Form ☐ Workshop ☐ Peer Review
☐ Report ☐ Reporting Form ☐ Diary ☐ Log ☐ Journal ☐ Inspection Form ☐ Usability Test ☐ Consents
☐ Acknowledgments ☐ Card Sorts ☐ Any other means of requesting information from 10 or more respondents (Explain):

☐ N/A
CDC 0.1490 (E), May 2014, CDC Adobe Acrobat 10.1, S508 Electronic Version, May 2014

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VI. Project Abstract/Summary (Provide justification by describing project’s purpose, objectives, funding conditions/intent, and
scope of Federal involvement):
This project will assess the extent to which PHHS Block Grant grantees achieved cross-cutting outcomes based on their use of flexible
grant funds to address prioritized public health needs. The objective is to demonstrate the accomplishments of grantees' public health
efforts and how the use of grant funds contributed to the results. Respondents include all 61 state, territorial, and tribal grantee health
departments, as represented by their block grant coordinators. Evaluators in ASREB will develop and disseminate the data collection
instrument, aggregate and analyze data, and report findings. Findings will be shared internal to CDC as well as with select stakeholders,
such as OMB.

VII. For determinations of “PRA Not Applicable” and “PRA Exemption/Exclusion Requested”, please provide a brief summary to
support the decision:

VIII. CIO-PRA Oversight Official/Representative Certification Statement

On behalf of this project, I certify that this determination decision is in accordance with 5 CFR Part 1320.

Corinne J.
Wigington -S

Digitally signed by Corinne
J. Wigington -S
Date: 2017.10.10 11:42:23
-04'00'

Health Scientist
Title

Signature
(FOR ICRO USE ONLY)
Audit Findings:

Selected for Audit?:

☐ OMB/PRA Clearance Not Required

10/10/2017
Date
☐ Yes

☐ OMB/PRA Clearance Required

ICRO Desk Officer: Name (Last, First)
ICRO Chief

Signature

☐ No

CDC ID No. 0920-17

CDC E-mail:
☐ Concur

Phone No.:

☐ Non-concur

03/29/2014
Date

CDC 0.1490 (E), May 2014, CDC Adobe Acrobat 10.1, S508 Electronic Version, May 2014

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