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 202406-0920-007 · OMB 0920-1282.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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
[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: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Requested	Previously Approved
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

table that charts IC Documents
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.