Information Collection Request

[NCSTLTPHIW] Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

ICR 202410-0920-015 · OMB 0920-0879 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-26-0203 STHA Engagement with HIE_WEB Form New Repair queued
Form 0920-26-0203 STHA Engagement with HIE_WORD Form New Repair queued
EPH Survey Form and Instruction New Repair queued
Rural Carveout Interview - SORH Form and Instruction New Repair queued
Rural Carveout Interview - SHD Form and Instruction New Repair queued
Rural Carveout Survey Form and Instruction New Repair queued
PGCoE Interim Assessment Focus Group Script/ Discussion Guide Form and Instruction New Repair queued
PGCoE Interim Assessment Survey Data Collection Tool Form and Instruction New Repair queued
Semi-Structured Interview Form and Instruction New Repair queued
Call for Data Form and Instruction New Repair queued
State Dental Director and Key Oral Health Program Staff Survey Form and Instruction New Repair queued
2025 Training Needs Assessment – U.S. Public Health Mycobacteriology Laboratories Online Questionnaire Form and Instruction New Repair queued
2024 Tuberculosis (TB) Training and Education Needs Assessment of the U.S.-affiliated Pacific Islands Form and Instruction Unchanged Available
[PHIC/NCHHSTP] 2024 TB Training and Education Needs Assessment – The U.S.-affiliated Pacific Islands – Online Survey Form and Instruction Unchanged Repair queued
Form 0920-0879 Case Study In-Depth Interview Guide Form and Instruction Unchanged Available
Form 0920-0879 Focus Group Discussion Guide—Advanced MAHC Use and Implementation Form and Instruction Unchanged Available
Form 0920-0879 Focus Group Discussion Guide—Moderate MAHC Use and Implementation Form and Instruction Unchanged Available
Form 0920-0879 Focus Group Discussion Guide—Moderate MAHC Use and Implementation Form and Instruction Unchanged Available
Form 0920-0879 MAHC Use and Acceptability Survey (EpiInfo Web Survey) Form Unchanged Available
Form 0920-0879 [PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) Form Unchanged Missing upstream
Form 0920-0879 O2DA Partner Evaluation Survey: Screener and Annotated Questionnaire Form and Instruction Unchanged Available
Form 0920-0879 O2DA Partner Evaluation Survey: Screener and Annotated Questionnaire Form and Instruction Unchanged Available
Form 0920-0879 [PHIC] Assessing Funded Overdose Data to Action (OD2A) Grantee Implementation and Impacts of Stop Overdose Campaigns Form and Instruction Unchanged Repair queued
CDC Funded Recipient Experience Survey Form and Instruction Unchanged Available
[PHIC] CDC Funded Recipient Experience Survey Form and Instruction Unchanged Missing upstream
OT20-2103 Success Stories Form Form and Instruction Unchanged Available
[PHIC] OT21-2103 Success Stories (2024-2026) Form and Instruction Unchanged Repair queued
Form 0920-0879 Hepatitis pediátrica de etiología desconocida. CONTROL del cuestionario sobre exposiciones (Entrevista a los padres) Form and Instruction Unchanged Available
Form 0920-0879 Hepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres) Form and Instruction Unchanged Available
Form 0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL (Parental Interview) Form and Instruction Unchanged Available
Form 0920-0879 Pediatric Hepatitis of Unknown Etiology - Exposures Questionnaire (Parental Interview) Form and Instruction Unchanged Repair queued
Form 0920-0879 PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD ABSTRACTION FORM Form and Instruction Unchanged Available
Form 0920-0879 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) Form and Instruction Unchanged Repair queued
AttG4_SurveyExtensionEmail.docx Supplementary Document Uploaded 2024-10-15 Available
AttG4_SurveyExtensionEmail.docx Supplementary Document Uploaded 2024-10-15 Available
0920-0879 MAHC Change Request_10112024.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-10-15 Available
0920-0879 MAHC Change Request_10112024.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-10-15 Repair queued
Attachment B - Approved GenICs under 0920-0879.docx Supplementary Document Uploaded 2023-06-20 Available
Attachment B - Approved GenICs under 0920-0879.docx Supplementary Document Uploaded 2023-06-20 Repair queued
Attachment C - 60 Day Federal Register Notice.pdf Supplementary Document Uploaded 2023-06-20 Available
Attachment C - 60 Day Federal Register Notice.pdf Supplementary Document Uploaded 2023-06-20 Repair queued
Attachment A - Public Health Service Act.pdf Supplementary Document Uploaded 2023-06-20 Available
Attachment A - Public Health Service Act.pdf Supplementary Document Uploaded 2023-06-20 Repair queued
SSB 0920_0879 extension.docx Supporting Statement B Uploaded 2023-06-20 Available
SSB 0920_0879 extension.docx Supporting Statement B Uploaded 2023-06-20 Repair queued
SSA 0920_0879_06142023_updated.docx Supporting Statement A Uploaded 2023-06-20 Available
SSA 0920_0879_06142023_updated.docx Supporting Statement A Uploaded 2023-06-20 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
281265 [PHIC] Health Data Utilities Assessment - 2026 Survey with Public Health Agencies Form NewSTHA Engagement with HIE_WEB
281265 [PHIC] Health Data Utilities Assessment - 2026 Survey with Public Health Agencies Form NewSTHA Engagement with HIE_WORD
277092 [PHIC/NCEH] EPH Practice Repository: Piloting the Collection and Dissemination of Environmental Public Health Practices (2025-2026) Form and Instruction NewEPH Survey
275800 [PHIC] 2025 Assessment of a Novel Funding Approach for Improving Health in Rural Communities Form and Instruction NewRural Carveout Interview - SORH
275800 [PHIC] 2025 Assessment of a Novel Funding Approach for Improving Health in Rural Communities Form and Instruction NewRural Carveout Interview - SHD
275800 [PHIC] 2025 Assessment of a Novel Funding Approach for Improving Health in Rural Communities Form and Instruction NewRural Carveout Survey
275332 [PHIC] 2025 U.S. Pathogen and Genomics Centers for Excellence (PGCoE) Interim Assessment Form and Instruction NewPGCoE Interim Assessment Focus Group Script/ Discussion Guide
275332 [PHIC] 2025 U.S. Pathogen and Genomics Centers for Excellence (PGCoE) Interim Assessment Form and Instruction NewPGCoE Interim Assessment Survey Data Collection Tool
274876 [PHIC] Developing Capacity to Decontaminate/Evacuate Vulnerable Persons During an Emergency (2025) Form and Instruction NewSemi-Structured Interview
274876 [PHIC] Developing Capacity to Decontaminate/Evacuate Vulnerable Persons During an Emergency (2025) Form and Instruction NewCall for Data
274775 [PHIC] Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery Other-Discontinue data collection New
274484 [PHIC] State Dental Director and Key Oral Health Program Staff Survey (2025) Form and Instruction NewState Dental Director and Key Oral Health Program Staff Survey
273560 [PHIC] 2025 Training Needs Assessment - U.S. Public Health Mycobacteriology Laboratories Online Questionnaire Form and Instruction New2025 Training Needs Assessment – U.S. Public Health Mycobacteriology Laboratories Online Questionnaire
269900 [PHIC/NCHHSTP] 2024 TB Training and Education Needs Assessment – The U.S.-affiliated Pacific Islands – Online Survey Form and Instruction Unchanged2024 Tuberculosis (TB) Training and Education Needs Assessment of the U.S.-affiliated Pacific Islands
269900 [PHIC/NCHHSTP] 2024 TB Training and Education Needs Assessment – The U.S.-affiliated Pacific Islands – Online Survey Form and Instruction Unchanged
269705 [PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) Form and Instruction UnchangedCase Study In-Depth Interview Guide
269705 [PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) Form and Instruction UnchangedFocus Group Discussion Guide—Advanced MAHC Use and Implementation
269705 [PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) Form and Instruction UnchangedFocus Group Discussion Guide—Moderate MAHC Use and Implementation
269705 [PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) Form and Instruction UnchangedFocus Group Discussion Guide—Moderate MAHC Use and Implementation
269705 [PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) Form UnchangedMAHC Use and Acceptability Survey (EpiInfo Web Survey)
269705 [PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) Form Unchanged
268184 [PHIC] Assessing Funded Overdose Data to Action (OD2A) Grantee Implementation and Impacts of Stop Overdose Campaigns Form and Instruction UnchangedO2DA Partner Evaluation Survey: Screener and Annotated Questionnaire
268184 [PHIC] Assessing Funded Overdose Data to Action (OD2A) Grantee Implementation and Impacts of Stop Overdose Campaigns Form and Instruction UnchangedO2DA Partner Evaluation Survey: Screener and Annotated Questionnaire
268184 [PHIC] Assessing Funded Overdose Data to Action (OD2A) Grantee Implementation and Impacts of Stop Overdose Campaigns Form and Instruction Unchanged
267334 [PHIC] CDC Funded Recipient Experience Survey Form and Instruction UnchangedCDC Funded Recipient Experience Survey
267334 [PHIC] CDC Funded Recipient Experience Survey Form and Instruction Unchanged
266981 [PHIC] OT21-2103 Success Stories (2024-2026) Form and Instruction UnchangedOT20-2103 Success Stories Form
266981 [PHIC] OT21-2103 Success Stories (2024-2026) Form and Instruction Unchanged
264737 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) Form and Instruction UnchangedHepatitis pediátrica de etiología desconocida. CONTROL del cuestionario sobre exposiciones (Entrevista a los padres)
264737 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) Form and Instruction UnchangedHepatitis pediátrica de etiología desconocida - Cuestionario sobre exposiciones (entrevista a los padres)
264737 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) Form and Instruction UnchangedPediatric Hepatitis of Unknown Etiology - Exposures Questionnaire CONTROL (Parental Interview)
264737 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) Form and Instruction UnchangedPediatric Hepatitis of Unknown Etiology - Exposures Questionnaire (Parental Interview)
264737 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) Form and Instruction UnchangedPEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD ABSTRACTION FORM
264737 [PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) Form and Instruction Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2026 08/31/2026 08/31/2026
162,000 0 162,000
162,000 0 162,000
0 0 0





Reginfo record details
14
table that charts list of burden
IC Title Form No. Form Name
[PHIC/NCEH] EPH Practice Repository: Piloting the Collection and Dissemination of Environmental Public Health Practices (2025-2026) n/a
[PHIC/NCEZID] Use and Acceptability of the Model Aquatic Health Code (2024) 0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879 ,   ,   ,   ,  
[PHIC/NCHHSTP] 2024 TB Training and Education Needs Assessment – The U.S.-affiliated Pacific Islands – Online Survey n/a
[PHIC/NCIRD] Pediatric Hepatitis-Adenovirus Case Control Evaluation, United States 2022-2026 (24CN) 0920-0879, 0920-0879, 0920-0879, 0920-0879, 0920-0879 ,   ,   ,   ,  
[PHIC] 2025 Assessment of a Novel Funding Approach for Improving Health in Rural Communities n/a, n/a, n/a ,   ,  
[PHIC] 2025 Training Needs Assessment - U.S. Public Health Mycobacteriology Laboratories Online Questionnaire n/a
[PHIC] 2025 U.S. Pathogen and Genomics Centers for Excellence (PGCoE) Interim Assessment n/a, n/a ,  
[PHIC] Assessing Funded Overdose Data to Action (OD2A) Grantee Implementation and Impacts of Stop Overdose Campaigns 0920-0879, 0920-0879 ,  
[PHIC] CDC Funded Recipient Experience Survey n/a
[PHIC] Developing Capacity to Decontaminate/Evacuate Vulnerable Persons During an Emergency (2025) n/a, n/a ,  
[PHIC] Health Data Utilities Assessment - 2026 Survey with Public Health Agencies 0920-26-0203, 0920-26-0203 ,  
[PHIC] Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery
[PHIC] OT21-2103 Success Stories (2024-2026) n/a
[PHIC] State Dental Director and Key Oral Health Program Staff Survey (2025) n/a

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 162,000 162,000 0 0 0 0
Annual Time Burden (Hours) 162,000 162,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No