Information Collection

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

IC 266981 under ICR 202410-0920-015 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

2026-08-07 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
[PHIC] OT21-2103 Success Stories (2024-2026)	Form and Instruction
OT20-2103 Success Stories Form [PHIC] OT21-2103 Success Stories (2024-2026)	Form and Instruction
OT20-2103 Success Stories Form Attachment B_ OT21-2103 Success Stories Form- REDCap_20240603.docx	Form and Instruction
OT20-2103 Success Stories Form Attachment B_ OT21-2103 Success Stories Form- REDCap_20240603.docx	Form and Instruction
Attachment A _ OT21-2103 Recipient List.docx Recipient List	IC Document
Attachment A _ OT21-2103 Recipient List.docx Recipient List	IC Document
Attachment B_ OT21-2103 Success Stories Form- REDCap.docx OT20-2103 Success Stories Form - Screenshots	IC Document
Attachment B_ OT21-2103 Success Stories Form- REDCap.docx OT20-2103 Success Stories Form - Screenshots	IC Document
Attachment D_ OT21-2103 Success Stories Guidance Document .docx Guidance Document	IC Document
Attachment D_ OT21-2103 Success Stories Guidance Document .docx Guidance Document	IC Document
Attachment E_ OT21-2103 Success Stories Email Announcement & Invitation .docx Email Announcement and Invitation	IC Document
Attachment E_ OT21-2103 Success Stories Email Announcement & Invitation .docx Email Announcement and Invitation	IC Document
Attachment F_ OT21-2103 Success Stories Reminder Message .docx Reminder Email	IC Document
Attachment F_ OT21-2103 Success Stories Reminder Message .docx Reminder Email	IC Document
OT21-2103 Success Stories_ Supporting Statement A_final.docx SSA	IC Document
OT21-2103 Success Stories_ Supporting Statement A_final.docx SSA	IC Document
OT21-2103 Success Stories_ Supporting Statement B_final.docx SSB	IC Document
OT21-2103 Success Stories_ Supporting Statement B_final.docx SSB	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

0920-0879-24ET

IC Status: Unchanged

Obligation to Respond: Voluntary

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	n/a				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 108

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	2,160	2,160
Annual IC Time Burden (Hours)	13,320	13,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recipient List		04/18/2024
OT20-2103 Success Stories Form - Screenshots		04/18/2024
Guidance Document		04/18/2024
Email Announcement and Invitation		04/18/2024
Reminder Email		04/18/2024
SSA		04/18/2024
SSB		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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