Information Collection

Preventive Health and Health Services Block Grant Assessment

IC 234732 under ICR 202204-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1257 Preventive Health and Health Services Block Grant Assessment Form and Instruction
Attachment 5 - Instrument Web Version.docx Other-Attachment 5 - Instrument Web
Attachment 5 - Instrument Web Version.docx Other-Attachment 5 - Instrument Web
0920-1257 PHHS Block Grant Coordinators, or designee Attachment 4- Instrument_word version.docx Form and Instruction
0920-1257 PHHS Block Grant Coordinators, or designee Attachment 4- Instrument_word version.docx Form and Instruction
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz IC Document
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz IC Document
Attachment 9 - Invitation Email.docx Attachment 9 - Invitation Email IC Document
Attachment 9 - Invitation Email.docx Attachment 9 - Invitation Email IC Document
Attachment 10 - Reminder Email.docx Attachment 10 - Reminder Email IC Document
Attachment 10 - Reminder Email.docx Attachment 10 - Reminder Email IC Document
Attachment 11 - Final Reminder Email.docx Attachment 11 - Final Reminder Email IC Document
Attachment 11 - Final Reminder Email.docx Attachment 11 - 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:	0920-1257

Is this a Common Form? No		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	0920-1257	PHHS Block Grant Coordinators, or designee	Attachment 4- Instrument_word version.docx		Yes	Yes	Fillable Fileable
Other-Attachment 5 - Instrument Web Version			Attachment 5 - Instrument Web Version.docx		No		Printable Only

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	Previously Approved
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
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz	Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx	04/25/2022
Attachment 9 - Invitation Email	Attachment 9 - Invitation Email.docx	04/25/2022
Attachment 10 - Reminder Email	Attachment 10 - Reminder Email.docx	04/25/2022
Attachment 11 - Final Reminder Email	Attachment 11 - Final Reminder Email.docx	04/25/2022

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