Information Collection

Preventive Health and Health Services Block Grant Assessment

IC 234732 under ICR 201901-0920-003 · OMB 0920-1257.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1257 can be found here:

Documents and Forms

Document Name Document Type
Attachment D_Instrument Word Version.docx Other-WORD
0920-XXXX Preventive Health and Health Services Block Grant Assess Attachment E - Instrument Web Version.docx Form
Attachment I - Invitation Email.docx Invitation Email IC Document
Attachment J - Reminder Email.docx Reminder Email IC Document
Attachment K - Final Reminder Email.docx Final Reminder Email IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Preventive Health and Health Services Block Grant Assessment	Agency IC Tracking Number:	0920-18AUV

Is this a Common Form? No		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
Other-WORD			Attachment D_Instrument Word Version.docx		No		Paper Only
Form	0920-XXXX	Preventive Health and Health Services Block Grant Assessment	Attachment E - Instrument Web 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: 61	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	61	61
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Invitation Email	Attachment I - Invitation Email.docx	01/17/2019
Reminder Email	Attachment J - Reminder Email.docx	01/17/2019
Final Reminder Email	Attachment K - Final Reminder Email.docx	01/17/2019

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