Information Collection

National Syringe Services Program Evaluation

IC 248417 under ICR 202203-0920-002 · OMB 0920-1359.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1359 can be found here:

2023-10-16 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form 0920-21DC National Syringe Services Program Evaluation Form and Instruction
0920-21DC Survey Year Two/Three Attachment 8_Survey_Year 2 and 3.docx Form and Instruction
0920-21DC Survey Year Two/Three Attachment 8_Survey_Year 2 and 3.docx Form and Instruction
0920-22DB Survey Year 1 OMB Approved SSP Survey_Year 1.docx Form and Instruction
0920-22DB Survey Year 1 OMB Approved SSP Survey_Year 1.docx Form and Instruction
Attachment 10_ Screenshots of Survey_Y1.pdf Screenshots Survey Year One IC Document
Attachment 10_ Screenshots of Survey_Y1.pdf Screenshots Survey Year One IC Document
Attachment 11_Screenshots of Survey_Y2-3.pdf Screenshots Survey Year Two/Three IC Document
Attachment 11_Screenshots of Survey_Y2-3.pdf Screenshots Survey Year Two/Three IC Document
Memo_Non-Substantive Change Request_0920-1359.docx Memo_Non-Substantive Change Request_0920-1359 IC Document
Memo_Non-Substantive Change Request_0920-1359.docx Memo_Non-Substantive Change Request_0920-1359 IC Document
SSP Survey OMB Change Justifications 2022.02.22.xlsx SSP Survey OMB Change Justifications 2022.02.22 IC Document
SSP Survey OMB Change Justifications 2022.02.22.xlsx SSP Survey OMB Change Justifications 2022.02.22 IC Document
SSP Evaluation_track changes_ NS change request_2022_02_17.docx SSP Evaluation_track changes_ NS change request_2022_02_17 IC Document
SSP Evaluation_track changes_ NS change request_2022_02_17.docx SSP Evaluation_track changes_ NS change request_2022_02_17 IC Document
SSP Evaluation_clean_ NS change request_2022_02_17.docx SSP Evaluation_clean_ NS change request_2022_02_17 IC Document
SSP Evaluation_clean_ NS change request_2022_02_17.docx SSP Evaluation_clean_ NS change request_2022_02_17 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	National Syringe Services Program Evaluation	Agency IC Tracking Number:	0920-22DB

Is this a Common Form? Yes		IC Status: Modified

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
Form and Instruction	0920-21DC	Survey Year Two/Three	Attachment 8_Survey_Year 2 and 3.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-22DB	Survey Year 1	OMB Approved SSP Survey_Year 1.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 480	Number of Respondents for Small Entity: 300

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Screenshots Survey Year One	Attachment 10_ Screenshots of Survey_Y1.pdf	07/16/2021
Screenshots Survey Year Two/Three	Attachment 11_Screenshots of Survey_Y2-3.pdf	07/16/2021
Memo_Non-Substantive Change Request_0920-1359	Memo_Non-Substantive Change Request_0920-1359.docx	03/01/2022
SSP Survey OMB Change Justifications 2022.02.22	SSP Survey OMB Change Justifications 2022.02.22.xlsx	03/01/2022
SSP Evaluation_track changes_ NS change request_2022_02_17	SSP Evaluation_track changes_ NS change request_2022_02_17.docx	03/01/2022
SSP Evaluation_clean_ NS change request_2022_02_17	SSP Evaluation_clean_ NS change request_2022_02_17.docx	03/01/2022

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