[PHIC] OT21-2103 Success Stories (2024-2026)

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

OMB: 0920-0879

IC ID: 266981

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
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Information Collection (IC) Details

View Information Collection (IC)

[PHIC] OT21-2103 Success Stories (2024-2026) 0920-0879-24ET
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction n/a OT20-2103 Success Stories Form Attachment B_ OT21-2103 Success Stories Form- REDCap_20240603.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

108 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,160 0 0 0 0 2,160
Annual IC Time Burden (Hours) 13,320 0 0 0 0 13,320
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Recipient List Attachment A _ OT21-2103 Recipient List.docx 04/18/2024
OT20-2103 Success Stories Form - Screenshots Attachment B_ OT21-2103 Success Stories Form- REDCap.docx 04/18/2024
Guidance Document Attachment D_ OT21-2103 Success Stories Guidance Document .docx 04/18/2024
Email Announcement and Invitation Attachment E_ OT21-2103 Success Stories Email Announcement & Invitation .docx 04/18/2024
Reminder Email Attachment F_ OT21-2103 Success Stories Reminder Message .docx 04/18/2024
SSA OT21-2103 Success Stories_ Supporting Statement A_final.docx 04/18/2024
SSB OT21-2103 Success Stories_ Supporting Statement B_final.docx 04/18/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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