[NCIPC] DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUATION

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-23AA Att. 6a Health Equity Capacity Assessment Updated	Form and Instruction	New	Available
Form 0920-23AA Health Equity Capacity Assessment	Form and Instruction	New	Repair queued
Form 0920-23AA Att. 5a Prevention Infrastructure Assessment Tool Updated	Form and Instruction	New	Available
Form 0920-23AA Prevention Infrastructure Assessment	Form and Instruction	New	Repair queued
Form 0920-23AA Att. 4b Key Informant Interview Protocol - Evaluator	Form and Instruction	New	Available
Form 0920-23AA Key Informant Interview Evaluator	Form and Instruction	New	Repair queued
Form 0920-23AA Att. 4a Key Informant Interview Protocol - Project Lead	Form and Instruction	New	Available
Form 0920-23AA Key Informant Interview – Project Lead	Form and Instruction	New	Repair queued
Form 0920-23AA Att. 3a APR Tool	Form and Instruction	New	Available
Form 0920-23AA Annual Performance Report	Form and Instruction	New	Repair queued
Att. 5b Prevention Infrastructure Assessment Screenshots Updated.pdf	Supplementary Document	Uploaded 2023-06-12	Repair queued
Att. 3b DELTA AHEAD APR Screenshots.docx.pdf	Supplementary Document	Uploaded 2023-06-12	Repair queued
Att. 1 - Authorizing Legislation - FVPSA 42 USC 10414.pdf	Supplementary Document	Uploaded 2023-06-12	Repair queued
SSA - DELTA AHEAD 5.16.23.docx	Supporting Statement A	Uploaded 2023-06-12	Repair queued
SSB - DELTA AHEAD - 5.16.23.docx	Supporting Statement B	Uploaded 2023-06-12	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
260627	Health Equity Capacity Assessment	Form and Instruction	New	Att. 6a Health Equity Capacity Assessment Updated
260627	Health Equity Capacity Assessment	Form and Instruction	New
260626	Prevention Infrastructure Assessment	Form and Instruction	New	Att. 5a Prevention Infrastructure Assessment Tool Updated
260626	Prevention Infrastructure Assessment	Form and Instruction	New
260625	Key Informant Interview Evaluator	Form and Instruction	New	Att. 4b Key Informant Interview Protocol - Evaluator
260625	Key Informant Interview Evaluator	Form and Instruction	New
260624	Key Informant Interview – Project Lead	Form and Instruction	New	Att. 4a Key Informant Interview Protocol - Project Lead
260624	Key Informant Interview – Project Lead	Form and Instruction	New
260623	Annual Performance Report	Form and Instruction	New	Att. 3a APR Tool
260623	Annual Performance Report	Form and Instruction	New

ICR Details

OMB Control No: 0920-1412	ICR Reference No: 202305-0920-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-23AA
Title: [NCIPC] DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUATION
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/29/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/13/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2026	36 Months From Approved
Responses	52	0	0
Time Burden (Hours)	163	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this data collection is to collect monitoring data project performance and implementation of cooperative agreement for Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Achieving Health Equity through Addressing Disparities (AHEAD). Information collected from recipients on state- and local-level will provide crucial data for performance monitoring of the cooperative agreement and will provide CDC with the capacity to respond in a timely manner to requests for information about the program from the Department of Health and Human Services (HHS), the White House, Congress, and other sources. Recipients will report progress and activity information to CDC on an annual schedule using a web-based Partners’ Portal and web-based survey tool.

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Authorizing Statute(s): None

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:
	87 FR 62859	10/17/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 37884	06/09/2023
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Annual Performance Report	0920-23AA	Att. 3a APR Tool
Health Equity Capacity Assessment	0920-23AA	Att. 6a Health Equity Capacity Assessment Updated
Key Informant Interview Evaluator	0920-23AA	Att. 4b Key Informant Interview Protocol - Evaluator
Key Informant Interview – Project Lead	0920-23AA	Att. 4a Key Informant Interview Protocol - Project Lead
Prevention Infrastructure Assessment	0920-23AA	Att. 5a Prevention Infrastructure Assessment Tool Updated

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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	52	0	0	52	0	0
Annual Time Burden (Hours)	163	0	0	163	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The Centers for Disease Control and Prevention (CDC) seeks OMB approval for three years for this new information collection request to collect information from 13 recipients (State Domestic Violence Coalitions) funded through CDC’s Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) AHEAD Program cooperative agreement. Three years of approval for 489 hours.

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Annual Cost to Federal Government: $38,832

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 06/13/2023

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