Information Collection

[CSTLTS] Performance Measures to Address COVID-19-Related Health Disparities in Support of the Implementation of the OT21-2103 COVID-19 Health Disparities Grant (carryover to 2023-2025)

IC 258150 under ICR 202301-0920-015 · OMB 0920-1282.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1282 can be found here:

2025-08-12 - No material or nonsubstantive change to a currently approved collection
2025-07-17 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Document Name Document Type
[CSTLTS] Performance Measures to Address COVID-19-Related Health Disparities in Support of the Implementation of the OT21-2103 COVID-19 Health Disparities Grant (carryover to 2023-2025) Form and Instruction
Modified Reporting Template for CDC OT21-2103 Performanc App B_1 Modified Reporting Template CDC OT21-2103_Performance Measures V2 Report.pdf Form and Instruction
Modified Reporting Template for CDC OT21-2103 Performanc App B_1 Modified Reporting Template CDC OT21-2103_Performance Measures V2 Report.pdf Form and Instruction
PPEO GenIC Request-CDC programs- CSTLTS_OT21-2103_2023-2025.pdf GENIC Request Template COVID-19 Disparities (carryover to 2023-2025) IC Document
PPEO GenIC Request-CDC programs- CSTLTS_OT21-2103_2023-2025.pdf GENIC Request Template COVID-19 Disparities (carryover to 2023-2025) IC Document
App A_Modified Technical Specs CDC OT21-2103 Performance Measure Guidance v2.pdf Modified Technical Specs and Performance Measures Guidance OT21-2103 IC Document
App A_Modified Technical Specs CDC OT21-2103 Performance Measure Guidance v2.pdf Modified Technical Specs and Performance Measures Guidance OT21-2103 IC Document
App B_2_CDC OT21-2103_Screenshots OT21-2103.pdf Screenshots OT21-2103 IC Document
App B_2_CDC OT21-2103_Screenshots OT21-2103.pdf Screenshots OT21-2103 IC Document
CSTLTS_OT21-2103-sample_draft_recipient_notification_ICRO.docx Sample Recipient Notification for OT21-2103 IC Document
CSTLTS_OT21-2103-sample_draft_recipient_notification_ICRO.docx Sample Recipient Notification for OT21-2103 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	[CSTLTS] Performance Measures to Address COVID-19-Related Health Disparities in Support of the Implementation of the OT21-2103 COVID-19 Health Disparities Grant (carryover to 2023-2025)	Agency IC Tracking Number:	0920-22IG

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	None	Modified Reporting Template for CDC OT21-2103 Performance Measures	App B_1 Modified Reporting Template CDC OT21-2103_Performance Measures V2 Report.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,296	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,296	1,296
Annual IC Time Burden (Hours)	45,360	45,360
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GENIC Request Template COVID-19 Disparities (carryover to 2023-2025)	PPEO GenIC Request-CDC programs- CSTLTS_OT21-2103_2023-2025.pdf	01/30/2023
Modified Technical Specs and Performance Measures Guidance OT21-2103	App A_Modified Technical Specs CDC OT21-2103 Performance Measure Guidance v2.pdf	01/30/2023
Screenshots OT21-2103	App B_2_CDC OT21-2103_Screenshots OT21-2103.pdf	01/30/2023
Sample Recipient Notification for OT21-2103	CSTLTS_OT21-2103-sample_draft_recipient_notification_ICRO.docx	01/30/2023

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