National Evaluation of the DP18-1815 Cooperative Agreement Program: Category B, Cardiovascular Disease Prevention and Management

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Resource Use and Cost Inventory Tool	Form and Instruction	Unchanged	Available
Cost Study Resource Use and Cost Inventory Tool – Partner/Site Level	Form and Instruction	Unchanged	Repair queued
CCL Partner-Site Key Informant Interview Guide	Form and Instruction	Unchanged	Available
CCL Partner Site-Level Informant Interview	Form and Instruction	Unchanged	Available
MTM Partner Site Interview Guide for Pharmacists	Form and Instruction	Unchanged	Available
MTM Partner Site Interview Guide	Form and Instruction	Unchanged	Available
MTM Partner Site-Level Interview	Form and Instruction	Unchanged	Repair queued
TBC Partner Site-Level Interview Guide	Form and Instruction	Unchanged	Available
TBC Partner Site-Level Interview	Form and Instruction	Unchanged	Repair queued
CQM Partner Site-level Interview Guide	Form and Instruction	Unchanged	Available
CQM Partner Site-Level Interview	Form and Instruction	Unchanged	Repair queued
Recipient Evaluation Year 5 Health Impact Statement	Form and Instruction	Unchanged	Available
Recipient Evaluation Year 4 Sustainability and Action Report Guidance	Form and Instruction	Unchanged	Available
Recipient Evalation Year 3 Effectiveness Brief	Form and Instruction	Unchanged	Available
Recipient-Led Evaluation Annual Report Template	Form and Instruction	Unchanged	Repair queued
Resource Use and Cost Inventory Tool	Form and Instruction	Unchanged	Available
Cost Study Resource Use and Cost Study Inventory Tool - Health Departments	Form and Instruction	Unchanged	Repair queued
CCL Health Department Group Discussion Guide	Form and Instruction	Unchanged	Available
CCL Group Discussion	Form and Instruction	Unchanged	Repair queued
CCL Health Department Interview Guide	Form and Instruction	Unchanged	Available
CCL Health Department Interview	Form and Instruction	Unchanged	Repair queued
TBC Group Discussion Guide	Form and Instruction	Unchanged	Available
TBC Group Discussion	Form and Instruction	Unchanged	Repair queued
MTM Health Department Interview Guide	Form and Instruction	Unchanged	Available
MTM Health Department Interview	Form and Instruction	Unchanged	Repair queued
TBC Health Department Interview Guide	Form and Instruction	Unchanged	Available
TBC Health Department Interview	Form and Instruction	Unchanged	Repair queued
CQM Health Department Group Discussion Guide	Form and Instruction	Unchanged	Available
CQM Group Discussion	Form and Instruction	Unchanged	Repair queued
CQM State Health Department Interview Guide	Form and Instruction	Unchanged	Repair queued
CQM Health Department Interview	Form and Instruction	Unchanged	Repair queued
SSA_1815 Category B_National Evaluation_v06_10-11-21.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-10-27	Repair queued
Att 9e. Cat B Case Study Follow Up Email.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 9d. Cat B Case Study Rem Email.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 9c. Cat B Case Study Confirm Email.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 9b. Cat B Case Study Partner Site Invite.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 9a. Cat B Case Study HD Invite_rev.docx	Supplementary Document	Uploaded 2020-12-02	Repair queued
Att 8b. Inst Rev Board App Not_Exemp Det_Pt B.PDF	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 8a. Inst Rev Board App Not_Exemp Det_Pt A.pdf	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 7. 60-day FRN.pdf	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 3f. Cat B 1815 Eval Gantt Chart.xlsx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 3e. Cat B 1815 Summ of Annual Resp.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 3d. Cat B Crosswalk Eval Comp_Data Coll Tools.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 3c. 1815 Logic Model.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 3b. 1815 Strat Prev_Control.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 3a. 1815 List of HD Awardees.docx	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 2. Auth Leg Sec 301a of PH Serv Act.pdf	Supplementary Document	Uploaded 2020-05-05	Repair queued
Att 1. CDC-RFA-DP18-1815PPHF18.pdf	Supplementary Document	Uploaded 2020-05-05	Repair queued
SSB_1815 Category B_v06_rev.docx	Supporting Statement B	Uploaded 2020-12-02	Repair queued
SSA_1815 Category B_v06_rev.docx	Supporting Statement A	Uploaded 2020-12-02	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
241440	Cost Study Resource Use and Cost Inventory Tool – Partner/Site Level	Form and Instruction	Unchanged	Resource Use and Cost Inventory Tool
241440	Cost Study Resource Use and Cost Inventory Tool – Partner/Site Level	Form and Instruction	Unchanged
241439	CCL Partner Site-Level Informant Interview	Form and Instruction	Unchanged	CCL Partner-Site Key Informant Interview Guide
241439	CCL Partner Site-Level Informant Interview	Form and Instruction	Unchanged
241438	MTM Partner Site-Level Interview	Form and Instruction	Unchanged	MTM Partner Site Interview Guide for Pharmacists
241438	MTM Partner Site-Level Interview	Form and Instruction	Unchanged	MTM Partner Site Interview Guide
241438	MTM Partner Site-Level Interview	Form and Instruction	Unchanged
241436	TBC Partner Site-Level Interview	Form and Instruction	Unchanged	TBC Partner Site-Level Interview Guide
241436	TBC Partner Site-Level Interview	Form and Instruction	Unchanged
241435	CQM Partner Site-Level Interview	Form and Instruction	Unchanged	CQM Partner Site-level Interview Guide
241435	CQM Partner Site-Level Interview	Form and Instruction	Unchanged
241434	Recipient-Led Evaluation Annual Report Template	Form and Instruction	Unchanged	Recipient Evaluation Year 5 Health Impact Statement
241434	Recipient-Led Evaluation Annual Report Template	Form and Instruction	Unchanged	Recipient Evaluation Year 4 Sustainability and Action Report Guidance
241434	Recipient-Led Evaluation Annual Report Template	Form and Instruction	Unchanged	Recipient Evalation Year 3 Effectiveness Brief
241434	Recipient-Led Evaluation Annual Report Template	Form and Instruction	Unchanged
241433	Cost Study Resource Use and Cost Study Inventory Tool - Health Departments	Form and Instruction	Unchanged	Resource Use and Cost Inventory Tool
241433	Cost Study Resource Use and Cost Study Inventory Tool - Health Departments	Form and Instruction	Unchanged
241432	CCL Group Discussion	Form and Instruction	Unchanged	CCL Health Department Group Discussion Guide
241432	CCL Group Discussion	Form and Instruction	Unchanged
241431	CCL Health Department Interview	Form and Instruction	Unchanged	CCL Health Department Interview Guide
241431	CCL Health Department Interview	Form and Instruction	Unchanged
241430	TBC Group Discussion	Form and Instruction	Unchanged	TBC Group Discussion Guide
241430	TBC Group Discussion	Form and Instruction	Unchanged
241428	MTM Health Department Interview	Form and Instruction	Unchanged	MTM Health Department Interview Guide
241428	MTM Health Department Interview	Form and Instruction	Unchanged
241426	TBC Health Department Interview	Form and Instruction	Unchanged	TBC Health Department Interview Guide
241426	TBC Health Department Interview	Form and Instruction	Unchanged
241425	CQM Group Discussion	Form and Instruction	Unchanged	CQM Health Department Group Discussion Guide
241425	CQM Group Discussion	Form and Instruction	Unchanged
241424	CQM Health Department Interview	Form and Instruction	Unchanged	CQM State Health Department Interview Guide
241424	CQM Health Department Interview	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1311	ICR Reference No: 202110-0920-012
Status: Historical Active	Previous ICR Reference No: 202003-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1311-22AG
Title: National Evaluation of the DP18-1815 Cooperative Agreement Program: Category B, Cardiovascular Disease Prevention and Management
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/14/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/27/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	12/31/2023	12/31/2023
Responses	253	0	253
Time Burden (Hours)	743	0	743
Cost Burden (Dollars)	30,515	0	30,515

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Abstract: This change request is requesting that HD-Level Recipient Interviews and Partner Site-Level Interviews be modified in order to schedule small group discussions in addition to one-on-one interviews with the same intended interviewee group when scheduling allows. This would offer group discussions as an option to the health department recipients and their healthcare partners, promoting richer discussion and reducing the number of total overall data collection events without increasing the overall burden hours. The attached supporting document (SSA) highlights the changes requested can be found on pp. 12, 13 and 16.

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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:
	84 FR 32185	07/05/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 29451	05/15/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
CCL Group Discussion	n/a	CCL Health Department Group Discussion Guide
CCL Health Department Interview	n/a	CCL Health Department Interview Guide
CCL Partner Site-Level Informant Interview	n/a	CCL Partner-Site Key Informant Interview Guide
CQM Group Discussion	n/a	CQM Health Department Group Discussion Guide
CQM Health Department Interview	n/a	CQM State Health Department Interview Guide
CQM Partner Site-Level Interview	n/a	CQM Partner Site-level Interview Guide
Cost Study Resource Use and Cost Inventory Tool – Partner/Site Level	n/a	Resource Use and Cost Inventory Tool
Cost Study Resource Use and Cost Study Inventory Tool - Health Departments	n/a	Resource Use and Cost Inventory Tool
MTM Health Department Interview	n/a	MTM Health Department Interview Guide
MTM Partner Site-Level Interview	n/a, n/a	MTM Partner Site Interview Guide ,   MTM Partner Site Interview Guide for Pharmacists
Recipient-Led Evaluation Annual Report Template	n/a, n/a, n/a	Recipient Evalation Year 3 Effectiveness Brief ,   Recipient Evaluation Year 4 Sustainability and Action Report Guidance ,   Recipient Evaluation Year 5 Health Impact Statement
TBC Group Discussion	n/a	TBC Group Discussion Guide
TBC Health Department Interview	n/a	TBC Health Department Interview Guide
TBC Partner Site-Level Interview	n/a	TBC Partner Site-Level Interview Guide

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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	253	253	0	0	0	0
Annual Time Burden (Hours)	743	743	0	0	0	0
Annual Cost Burden (Dollars)	30,515	30,515	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: This is a new information collection request.

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Annual Cost to Federal Government: $1,041,626

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.     Yes

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: 10/27/2021

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