Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Evaluation Capacity and Practicum Experience among Past Practicum Participants (2018-2022) (INTERVIEW)	Form and Instruction	New	Repair queued
Evaluation Progress and Capacity Assessment among Past CDC Harvard Practicum Participants (2018-2022) (SURVEY) (screen shots)	Form and Instruction	New	Repair queued
Evaluation Progress and Capacity Assessment among Past CDC Harvard Practicum Participants (2018-2022) (SURVEY)	Form and Instruction	New	Repair queued
Evaluation Progress and Capacity Building among Participants from the 2023 CDC Harvard Practicum (12-Month Interview)	Form and Instruction	New	Repair queued
Evaluation Progress and Capacity Assessment among 2023 CDC Harvard Practicum Participants (12-Month Survey) (screen shots)	Form and Instruction	New	Repair queued
Evaluation Progress and Capacity Assessment among 2023 CDC Harvard Practicum Participants (12-Month Survey)	Form and Instruction	New	Repair queued
Progress of Evaluation Implementation from 2023 CDC Harvard Practicum Participants (6-Month Survey) (screen shots)	Form and Instruction	New	Repair queued
Progress of Evaluation Implementation from 2023 CDC Harvard Practicum Participants (6-Month Survey)	Form and Instruction	New	Repair queued
Training Feedback from 2023 MCH Program Participants (3-Month Survey) (screen shots)	Form and Instruction	New	Repair queued
Training Feedback from 2023 MCH Program Participants (3-Month Survey)	Form and Instruction	New	Repair queued
Form 0920-0879-23EX Attachment B- Time Motion Data Collection Excel	Form and Instruction	New	Repair queued
Form 0920-0879-23EX Attachment A- Participant Exercise Overview Form	Form and Instruction	New	Repair queued
Form 0920-23EV Attachment C_OT21-2103 Success Stories Form- Word	Form and Instruction	New	Repair queued
Annual Report of Cancer Inquiries to STLTs	Form and Instruction	New	Repair queued
Cancer Intake Inquiry Form - EpiInfo	Form and Instruction	New	Repair queued
Cancer Intake Inquiry Form - Redcap	Form and Instruction	New	Repair queued
NSSP BioSense Platform User Assessment for Site Administrators, 2023	Form and Instruction	New	Repair queued
NSSP BioSense Platform User Assessment, 2023	Form and Instruction	New	Repair queued
Form 0920-0879 Disease Intervention Professional Enumeration Study (State & Territorial)	Form and Instruction	New	Repair queued
Form 0920-0879 Disease Intervention Professional Enumeration Study (Local)	Form and Instruction	New	Repair queued
CLPPP-WIC Workgroup Interview Questions	Form and Instruction	New	Repair queued
Form 0920-0879 Six-Month Follow-up Survey of PHIT Registrants from PH Agencies	Form	New	Repair queued
Early Care and Education (ECE) 2022 State Indicator Assessment	Form and Instruction	New	Repair queued
Form 0920-0879 Six-Month Follow-up Survey of PHIT Registrants from Public Health Agencies	Form and Instruction	New	Repair queued
ATSDR Stakeholder Survey to Determine Surveillance Needs	Form and Instruction	New	Repair queued
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire CONTROL (Spanish)	Form	New	Repair queued
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire CONTROL	Form	New	Repair queued
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire (Spanish)	Form	New	Repair queued
Form 0920-0879 Pediatric Hepatitis - Exposure Questionnaire	Form	New	Repair queued
Form 0920-0879 Pediatric Hepatitis - MEDICAL RECORD ABSTRACTION FORM	Form	New	Repair queued
Form Focus Group Modera 0920-22ID	Form and Instruction	New	Repair queued
Form Survey 0920-22ID	Form and Instruction	New	Repair queued
Form 0920-0879 State, Tribal, Local, and Territorial PHIT Attendee Follow-up Survey	Form and Instruction	New	Repair queued
Form 0920-0879 Focus Group Instrument	Form and Instruction	New	Available
Form 0920-0879 Online Instrument	Form and Instruction	New	Available
Attachment B_Approved GenICs under 0920-0879 updated 050120.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
2020-11001.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
Attachment B_Approved GenICs under 0920-0879 updated 112017.docx	Supplementary Document	Uploaded 2017-11-20	Repair queued
Statement B 0879 extension 101920.docx	Supporting Statement B	Uploaded 2020-11-23	Repair queued
Statement A 0879 extension 101920.docx	Supporting Statement A	Uploaded 2020-11-23	Repair queued
Attachment A Public Health Service Act.doc	Supplementary Document	Uploaded 2017-11-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Evaluation Capacity and Practicum Experience among Past Practicum Participants (2018-2022) (INTERVIEW)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Evaluation Progress and Capacity Assessment among Past CDC Harvard Practicum Participants (2018-2022) (SURVEY) (screen shots)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Evaluation Progress and Capacity Assessment among Past CDC Harvard Practicum Participants (2018-2022) (SURVEY)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Evaluation Progress and Capacity Building among Participants from the 2023 CDC Harvard Practicum (12-Month Interview)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Evaluation Progress and Capacity Assessment among 2023 CDC Harvard Practicum Participants (12-Month Survey) (screen shots)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Evaluation Progress and Capacity Assessment among 2023 CDC Harvard Practicum Participants (12-Month Survey)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Progress of Evaluation Implementation from 2023 CDC Harvard Practicum Participants (6-Month Survey) (screen shots)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Progress of Evaluation Implementation from 2023 CDC Harvard Practicum Participants (6-Month Survey)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Training Feedback from 2023 MCH Program Participants (3-Month Survey) (screen shots)
260194	[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	Form and Instruction	New	Training Feedback from 2023 MCH Program Participants (3-Month Survey)
260191	[CSTLTS] Emergency Response and Planning Time Motion Study Data Collection	Form and Instruction	New	Attachment B- Time Motion Data Collection Excel
260191	[CSTLTS] Emergency Response and Planning Time Motion Study Data Collection	Form and Instruction	New	Attachment A- Participant Exercise Overview Form
260076	[CSTLTS] OT21-23 Success Stories	Form and Instruction	New	Attachment C_OT21-2103 Success Stories Form- Word
259905	[CSTLTS] Pilot Reporting of Cancer Inquiries by the Public to STLT Partners	Form and Instruction	New	Annual Report of Cancer Inquiries to STLTs
259905	[CSTLTS] Pilot Reporting of Cancer Inquiries by the Public to STLT Partners	Form and Instruction	New	Cancer Intake Inquiry Form - EpiInfo
259905	[CSTLTS] Pilot Reporting of Cancer Inquiries by the Public to STLT Partners	Form and Instruction	New	Cancer Intake Inquiry Form - Redcap
259660	[CSTLTS] National Syndromic Surveillance System Program's BioSense Platform Assessment, 2023	Form and Instruction	New	NSSP BioSense Platform User Assessment for Site Administrators, 2023
259660	[CSTLTS] National Syndromic Surveillance System Program's BioSense Platform Assessment, 2023	Form and Instruction	New	NSSP BioSense Platform User Assessment, 2023
259660	[CSTLTS] National Syndromic Surveillance System Program's BioSense Platform Assessment, 2023	Other-WORD version of user survey content to facilitate review	New
258835	[CSTLTS] Disease Intervention Specialist (DIS) Workforce Assessment	Form and Instruction	New	Disease Intervention Professional Enumeration Study (State & Territorial)
258835	[CSTLTS] Disease Intervention Specialist (DIS) Workforce Assessment	Form and Instruction	New	Disease Intervention Professional Enumeration Study (Local)
258720	[CSTLTS / NCEH] Exploration of CDC and WIC Partnerships for Childhood Lead Poisoning Prevention	Form and Instruction	New	CLPPP-WIC Workgroup Interview Questions
257172	[CSTLTS] Six-Month Follow-up Survey of PHIT Registrants from PH Agencies	Form	New	Six-Month Follow-up Survey of PHIT Registrants from PH Agencies
257172	[CSTLTS] Six-Month Follow-up Survey of PHIT Registrants from PH Agencies	Other-WORD	New
257131	[CSTLTS] Early Care and Education (ECE) State Indicator Assessment 2022	Form and Instruction	New	Early Care and Education (ECE) 2022 State Indicator Assessment
257131	[CSTLTS] Early Care and Education (ECE) State Indicator Assessment 2022	Other-WORD version of survey content to facilitate review	New
256936	[CSELS] Six-Month Follow-up Survey of PHIT Registrants from PH Agencies	Form and Instruction	New	Six-Month Follow-up Survey of PHIT Registrants from Public Health Agencies
256936	[CSELS] Six-Month Follow-up Survey of PHIT Registrants from PH Agencies	Other-WORD	New
256934	[CSTLTS] ATSDR Public Health Surveillance Stakeholder Input and Priorities	Form and Instruction	New	ATSDR Stakeholder Survey to Determine Surveillance Needs
256747	[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023	Form	New	Pediatric Hepatitis - Exposure Questionnaire CONTROL (Spanish)
256747	[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023	Form	New	Pediatric Hepatitis - Exposure Questionnaire CONTROL
256747	[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023	Form	New	Pediatric Hepatitis - Exposure Questionnaire (Spanish)
256747	[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023	Form	New	Pediatric Hepatitis - Exposure Questionnaire
256747	[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023	Form	New	Pediatric Hepatitis - MEDICAL RECORD ABSTRACTION FORM
255304	Improving Processes for Identifying and Reporting Disaster-Related Deaths CDC Guidance Knowledge Assessment	Form and Instruction	New	0920-22ID
255304	Improving Processes for Identifying and Reporting Disaster-Related Deaths CDC Guidance Knowledge Assessment	Form and Instruction	New	0920-22ID
250062	State, Tribal, Local, and Territorial PHIT Attendee Follow-up Survey	Form and Instruction	New	State, Tribal, Local, and Territorial PHIT Attendee Follow-up Survey
246199	Pandemics, Natural Disasters, and other Interruption of Service Events: Contingency Planning Considerations for Mycobacteriology Testing	Form and Instruction	New	Focus Group Instrument
246199	Pandemics, Natural Disasters, and other Interruption of Service Events: Contingency Planning Considerations for Mycobacteriology Testing	Form and Instruction	New	Online Instrument

ICR Details

OMB Control No: 0920-0879	ICR Reference No: 202011-0920-003
Status: Historical Active	Previous ICR Reference No: 201711-0920-012
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0879
Title: Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/13/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/30/2020
Terms of Clearance: Previous Terms of clearance continue: Approved consistent with the understanding that CDC will use this generic specifically for routine communications with public health officials to assess capacity and needs. This would not be the vehicle for submitting ICRs for gathering information from grantees about program performance or gathering in-depth information about programmatic needs. For ICs submitted under this generic ICR, CDC agrees to submit individual collections to OMB, along with all necessary supporting statements (to include information about research design and analysis, burden estimates, approaches to address non-response bias, etc).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2024	36 Months From Approved	01/31/2021
Responses	162,000	0	162,000
Time Burden (Hours)	162,000	0	162,000
Cost Burden (Dollars)	3,763,260	0	3,763,260

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Abstract: CDC requests an Extension to the Generic Clearance to continue to collect information related to domestic public health issues and services that affect state, tribal, local, and territorial STLT governmental entities.

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Authorizing Statute(s): US Code: 42 USC 301 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:
	85 FR 30962	05/21/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 73718	11/19/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Improving Processes for Identifying and Reporting Disaster-Related Deaths CDC Guidance Knowledge Assessment	Focus Group Moderator Guide, Survey	0920-22ID ,   0920-22ID
Pandemics, Natural Disasters, and other Interruption of Service Events: Contingency Planning Considerations for Mycobacteriology Testing	0920-0879, 0920-0879	Online Instrument ,   Focus Group Instrument
State, Tribal, Local, and Territorial PHIT Attendee Follow-up Survey	0920-0879	State, Tribal, Local, and Territorial PHIT Attendee Follow-up Survey
[CSELS] Six-Month Follow-up Survey of PHIT Registrants from PH Agencies	0920-0879	Six-Month Follow-up Survey of PHIT Registrants from Public Health Agencies
[CSTLTS / NCEH] Exploration of CDC and WIC Partnerships for Childhood Lead Poisoning Prevention	None	CLPPP-WIC Workgroup Interview Questions
[CSTLTS, NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States, 2022 – 2023	0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879	Pediatric Hepatitis - MEDICAL RECORD ABSTRACTION FORM ,   Pediatric Hepatitis - Exposure Questionnaire ,   Pediatric Hepatitis - Exposure Questionnaire (Spanish) ,   Pediatric Hepatitis - Exposure Questionnaire CONTROL ,   Pediatric Hepatitis - Exposure Questionnaire CONTROL (Spanish)
[CSTLTS] ATSDR Public Health Surveillance Stakeholder Input and Priorities	n/a	ATSDR Stakeholder Survey to Determine Surveillance Needs
[CSTLTS] Assessing Outcomes of the CDC-Harvard Program Evaluation Practicum in Building Program Evaluation Capacity in STLT Maternal and Child Health Programs (2023)	None, None, None, None, None, None, None, None, None, None	Training Feedback from 2023 MCH Program Participants (3-Month Survey) ,   Training Feedback from 2023 MCH Program Participants (3-Month Survey) (screen shots) ,   Progress of Evaluation Implementation from 2023 CDC Harvard Practicum Participants (6-Month Survey) ,   Progress of Evaluation Implementation from 2023 CDC Harvard Practicum Participants (6-Month Survey) (screen shots) ,   Evaluation Progress and Capacity Assessment among 2023 CDC Harvard Practicum Participants (12-Month Survey) ,   Evaluation Progress and Capacity Assessment among 2023 CDC Harvard Practicum Participants (12-Month Survey) (screen shots) ,   Evaluation Progress and Capacity Building among Participants from the 2023 CDC Harvard Practicum (12-Month Interview) ,   Evaluation Progress and Capacity Assessment among Past CDC Harvard Practicum Participants (2018-2022) (SURVEY) ,   Evaluation Progress and Capacity Assessment among Past CDC Harvard Practicum Participants (2018-2022) (SURVEY) (screen shots) ,   Evaluation Capacity and Practicum Experience among Past Practicum Participants (2018-2022) (INTERVIEW)
[CSTLTS] Disease Intervention Specialist (DIS) Workforce Assessment	0920-0879, 0920-0879	Disease Intervention Professional Enumeration Study (Local) ,   Disease Intervention Professional Enumeration Study (State & Territorial)
[CSTLTS] Early Care and Education (ECE) State Indicator Assessment 2022	None	Early Care and Education (ECE) 2022 State Indicator Assessment
[CSTLTS] Emergency Response and Planning Time Motion Study Data Collection	0920-0879-23EX, 0920-0879-23EX	Attachment A- Participant Exercise Overview Form ,   Attachment B- Time Motion Data Collection Excel
[CSTLTS] National Syndromic Surveillance System Program's BioSense Platform Assessment, 2023	None, None	NSSP BioSense Platform User Assessment, 2023 ,   NSSP BioSense Platform User Assessment for Site Administrators, 2023
[CSTLTS] OT21-23 Success Stories	0920-23EV	Attachment C_OT21-2103 Success Stories Form- Word
[CSTLTS] Pilot Reporting of Cancer Inquiries by the Public to STLT Partners	n/a, n/a, n/a	Cancer Intake Inquiry Form - Redcap ,   Cancer Intake Inquiry Form - EpiInfo ,   Annual Report of Cancer Inquiries to STLTs
[CSTLTS] Six-Month Follow-up Survey of PHIT Registrants from PH Agencies	0920-0879	Six-Month Follow-up Survey of PHIT Registrants from PH Agencies

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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	162,000	162,000	0	0	0	0
Annual Time Burden (Hours)	162,000	162,000	0	0	0	0
Annual Cost Burden (Dollars)	3,763,260	3,763,260	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $92,950

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? No

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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: 11/30/2020

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