Evaluation of Public Health AmeriCorps

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 06 Grantee Technical Assistance and Training Form	Form and Instruction	New	Available
Form 06 Training and TA Form	Form and Instruction	New	Repair queued
Form 02 Grantee Survey	Form and Instruction	New	Available
Form 02 Grantee Survey	Form and Instruction	New	Repair queued
Form 01 Member Alumni Survey and Early Exit Survey	Form and Instruction	New	Repair queued
Form 01 Early Exit Survey	Form and Instruction	New	Repair queued
Form 01 Member Alumni Survey and Early Exit Survey	Form and Instruction	New	Available
Form 01 Member Alumni Survey	Form and Instruction	New	Repair queued
30-Day Notice_02-06-24.pdf	Supplementary Document	Uploaded 2024-02-06	Repair queued
60-Day PHA Evaluation.pdf	Supplementary Document	Uploaded 2024-01-29	Repair queued
42 U.S.C. 12639.pdf	Supplementary Document	Uploaded 2024-01-29	Repair queued
EO 13996.pdf	Supplementary Document	Uploaded 2024-01-29	Repair queued
3045-NEW PHA Member Outcome Surveys_SSB.docx	Supporting Statement B	Uploaded 2024-01-29	Repair queued
3045-NEW PHA Member outcome Surveys_SSA.docx	Supporting Statement A	Uploaded 2024-01-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
264766	Partner Interview	Other-Interview Questions	New
264765	Early Exit Interview	Other-Interview Questions	New
264764	Grantee Focus Group	Other-Focus Group Questions	New
264741	Training and TA Form	Form and Instruction	New	Grantee Technical Assistance and Training Form
264741	Training and TA Form	Form and Instruction	New
264740	Grantee Survey	Form and Instruction	New	Grantee Survey
264740	Grantee Survey	Form and Instruction	New
264739	Early Exit Survey	Form and Instruction	New	Member Alumni Survey and Early Exit Survey
264739	Early Exit Survey	Form and Instruction	New
264738	Member Alumni Survey	Form and Instruction	New	Member Alumni Survey and Early Exit Survey
264738	Member Alumni Survey	Form and Instruction	New

ICR Details

OMB Control No: 3045-0199	ICR Reference No: 202311-3045-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: CNCS	Agency Tracking No:
Title: Evaluation of Public Health AmeriCorps
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 with change	Conclusion Date: 04/04/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/06/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2027	36 Months From Approved
Responses	2,198	0	0
Time Burden (Hours)	2,097	0	0
Cost Burden (Dollars)	99,267	0	0

---

Abstract: This information collection includes a survey of Public Health AmeriCorps (PHA) members, a survey of PHA grantees and a PHA grantee training and technical assistance form, and questions for PHA grantees who choose to participate in focus groups, to allow AmeriCorps to evaluate the success of PHA in meeting its goals of addressing public health needs and developing the next generation of public health leaders.

---

Authorizing Statute(s): EO: EO 13996 Name/Subject of EO: Establishing the COVID-19 Pandemic Testing Board and Ensuring a Sustainable Public Health Workforce
   US Code: 42 USC 12639 Name of Law: National and Community Service Act, as amended
  

Citations for New Statutory Requirements: EO: EO 13996 Name/Subject of EO: Establishing the COVID-19 Pandemic Testing Board and Ensuring a Sustainable Public Health Workforce

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 61575	09/07/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 8184	02/06/2024
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Early Exit Interview
Early Exit Survey	01	Member Alumni Survey and Early Exit Survey
Grantee Focus Group
Grantee Survey	02	Grantee Survey
Member Alumni Survey	01	Member Alumni Survey and Early Exit Survey
Partner Interview
Training and TA Form	06	Grantee Technical Assistance and Training Form

---

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	2,198	0	0	2,198	0	0
Annual Time Burden (Hours)	2,097	0	0	2,097	0	0
Annual Cost Burden (Dollars)	99,267	0	0	99,267	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: This new collection is due to a “Program Change Due to Agency Discretion” because it is necessary to implement Executive Order 13996, Establishing the COVID-19 Pandemic Testing Board and Ensuring a Sustainable Public Health Workforce.

---

Annual Cost to Federal Government: $120,522

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.     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? Yes

---

Common Form ICR:  No

---

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: 02/06/2024

---