Recipient Information Instruments

OMB Co. No: 0920-0106 Expiration #:

PHHS BLOCK GRANT INFORMATION SYSTEM DEVELOPMENT PROJECT

Attachment D: BGIS Recipient Information Data Collection Instruments

Attachment D: Block Grant Information System (BGIS) Recipient Information Data Collection Instruments

User Profile Data Collection Instrument 2

Health Department or Agency Data Collection Instrument 5

Lead Health Official Data Collection Instrument 7

Chief Executive Officer Data Collection Instrument 9

Recipient Health Objective Data Collection Instrument 11

CDC estimates the average public reporting burden for this collection of information as 2 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0106).

User Profile Data Collection Instrument

Create a User Profile for everyone who will be using the new system. Users who do not have system admin or team lead permissions cannot edit the user role.

1. Work Email: [auto-generated from user login]

2. Role: *Choose one (assigned by System Admin or Team Lead)

   • CDC Team Lead

   • CDC Project Officer

   • Recipient BG Coordinator

   • Recipient Program Manager

   • CDC Operations Team

   • CDC OGS

   • CDC Evaluation

3. Recipient: [System Admin or Team Lead Assigns]

4. First Name: [Short Text]

5. Last Name: [Short Text]

6. Address: [Short Text]

7. City: [Short Text]

8. State: *Choose one

   • Alabama

   • Alaska

   • American Samoa

   • Arizona

   • Arkansas

   • California

   • Colorado

   • Connecticut

   • Delaware

   • District of Columbia

   • Federated States of Micronesia

   • Florida

   • Georgia

   • Guam

   • Hawaii

   • Idaho

   • Illinois

   • Indiana

   • Iowa

   • Kansas

   • Kentucky

   • Kickapoo Tribe

   • Louisiana

   • Maine

   • Marshall Islands

   • Maryland

   • Massachusetts

   • Michigan

   • Minnesota

   • Mississippi

   • Missouri

   • Montana

   • N. Mariana Islands

   • Nebraska

   • Nevada

   • New Hampshire

   • New Jersey

   • New Mexico

   • New York

   • North Carolina

   • North Dakota

   • Ohio

   • Oklahoma

   • Oregon

   • Pennsylvania

   • Puerto Rico

   • Republic of Palau

   • Rhode Island

   • Santee Sioux

   • South Carolina

   • South Dakota

   • Tennessee

   • Texas

   • U.S. Virgin Islands

   • Utah

   • Vermont

   • Virginia

   • Washington

   • West Virginia

   • Wisconsin

   • Wyoming

9. Zip Code: [Short Text]

10. Work Phone Number: [Short Text] (Allow multiple entries)

11. Work Fax Number: [Short Text] (optional)

Health Department or Agency Data Collection Instrument

Please answer the following questions about the health department or agency in your jurisdiction responsible for the PHHS Block Grant funds.

1. Recipient: [auto-populates]

2. Health Department or Agency Name: [Short Text]

3. Address: [Short Text]

4. City: [Short Text]

5. State: *Choose one

   • Alabama

   • Alaska

   • American Samoa

   • Arizona

   • Arkansas

   • California

   • Colorado

   • Connecticut

   • Delaware

   • District of Columbia

   • Federated States of Micronesia

   • Florida

   • Georgia

   • Guam

   • Hawaii

   • Idaho

   • Illinois

   • Indiana

   • Iowa

   • Kansas

   • Kentucky

   • Kickapoo Tribe

   • Louisiana

   • Maine

   • Marshall Islands

   • Maryland

   • Massachusetts

   • Michigan

   • Minnesota

   • Mississippi

   • Missouri

   • Montana

   • N. Mariana Islands

   • Nebraska

   • Nevada

   • New Hampshire

   • New Jersey

   • New Mexico

   • New York

   • North Carolina

   • North Dakota

   • Ohio

   • Oklahoma

   • Oregon

   • Pennsylvania

   • Puerto Rico

   • Republic of Palau

   • Rhode Island

   • Santee Sioux

   • South Carolina

   • South Dakota

   • Tennessee

   • Texas

   • U.S. Virgin Islands

   • Utah

   • Vermont

   • Virginia

   • Washington

   • West Virginia

   • Wisconsin

   • Wyoming

6. Zip Code: [Short Text]

7. Website: [Short Text]

Lead Health Official Data Collection Instrument

1. Recipient: [Auto-populates from User Profile]

2. Recipient Lead Health Official Name: [Short Text]

3. Address: [Short Text]

4. City: [Short Text]

5. State: *Choose one

   • Alabama

   • Alaska

   • American Samoa

   • Arizona

   • Arkansas

   • California

   • Colorado

   • Connecticut

   • Delaware

   • District of Columbia

   • Federated States of Micronesia

   • Florida

   • Georgia

   • Guam

   • Hawaii

   • Idaho

   • Illinois

   • Indiana

   • Iowa

   • Kansas

   • Kentucky

   • Kickapoo Tribe

   • Louisiana

   • Maine

   • Marshall Islands

   • Maryland

   • Massachusetts

   • Michigan

   • Minnesota

   • Mississippi

   • Missouri

   • Montana

   • N. Mariana Islands

   • Nebraska

   • Nevada

   • New Hampshire

   • New Jersey

   • New Mexico

   • New York

   • North Carolina

   • North Dakota

   • Ohio

   • Oklahoma

   • Oregon

   • Pennsylvania

   • Puerto Rico

   • Republic of Palau

   • Rhode Island

   • Santee Sioux

   • South Carolina

   • South Dakota

   • Tennessee

   • Texas

   • U.S. Virgin Islands

   • Utah

   • Vermont

   • Virginia

   • Washington

   • West Virginia

   • Wisconsin

   • Wyoming

6. Zip Code: [Short Text]

7. Phone Number: [Short Text]

8. Email Address: [Short Text]

9. Website: [Short Text]

Chief Executive Officer Data Collection Instrument

Please answer the following questions about the chief executive officer of your jurisdiction (e.g., governor, chief, president, tribal chairman)

1. Recipient: [Auto-populated]

2. Chief Executive Officer Name: [Short Text]

3. Title: [Short Text]

4. Address: [Short Text]

5. City: [Short Text]

6. State: *Choose one

   • Alabama

   • Alaska

   • American Samoa

   • Arizona

   • Arkansas

   • California

   • Colorado

   • Connecticut

   • Delaware

   • District of Columbia

   • Federated States of Micronesia

   • Florida

   • Georgia

   • Guam

   • Hawaii

   • Idaho

   • Illinois

   • Indiana

   • Iowa

   • Kansas

   • Kentucky

   • Kickapoo Tribe

   • Louisiana

   • Maine

   • Marshall Islands

   • Maryland

   • Massachusetts

   • Michigan

   • Minnesota

   • Mississippi

   • Missouri

   • Montana

   • N. Mariana Islands

   • Nebraska

   • Nevada

   • New Hampshire

   • New Jersey

   • New Mexico

   • New York

   • North Carolina

   • North Dakota

   • Ohio

   • Oklahoma

   • Oregon

   • Pennsylvania

   • Puerto Rico

   • Republic of Palau

   • Rhode Island

   • Santee Sioux

   • South Carolina

   • South Dakota

   • Tennessee

   • Texas

   • U.S. Virgin Islands

   • Utah

   • Vermont

   • Virginia

   • Washington

   • West Virginia

   • Wisconsin

   • Wyoming

7. Zip Code: [Short Text]

8. Website: [Short Text]

9. Term of Office: [Date Range: mm/yyyy to mm/yyyy]

10. Delegated Official Name (The designee must be a cabinet-level position within the jurisdiction): [Short Text]

Recipient Health Objective Data Collection Instrument

Recipients will add their Recipient Health Objectives in this UIC. Recipient Health Objectives are typically objectives that last longer than the performance period of the PHHS Block Grant; they are objectives to be met over roughly five years. Block Grant and Program Manager (BG/PM) user roles should have the ability to add and delete Recipient Health Objective entries as needed. User should be able to place the information in the order they desire.

1. Add Recipient Health Objective: [Short Text]

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