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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.