Program Evaluation of CDC’s Core State Injury Prevention Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1365 SpecialEmphasisRpt_CoreSIPP	Form	Modified	Repair queued
Form 0920-21GB Special Emphasis Report Examples	Form and Instruction	Modified	Available
Form 0920-21GB Special Emphasis Reports	Form and Instruction	Modified	Repair queued
Form 0920-1365 HosDischargeInjuryIndicator_CoreSIPP	Form	Modified	Available
Form 0920-1365 Hospital Discharge Injury Indicators	Form	Modified	Repair queued
Form 0920-1365 ERDEPTInjuryIndicator_CoreSIPP	Form	Modified	Available
Form 0920-1365 Emergency Department Injury Indicators	Form	Modified	Missing upstream
Form 0920-1365 DeathInjuryIndicator_CoreSIPP	Form	Modified	Available
Form 0920-1365 Injury Indicators	Form	Modified	Available
Form 0920-1365 RECGroupInterview_CoreSIPP	Form	Modified	Available
Form 0920-1365 Recipient-level Group Interviews	Form	Modified	Repair queued
Form 0920-1365 EcoIndicatorCostTool_CoreSIPP	Form	Modified	Repair queued
Form 0920-1365 Economic Indicators	Form	Modified	Repair queued
Form 0920-1365 ImplementCapRubric_CoreSIPP	Form	Modified	Available
Form 0920-1365 Implementation Capacity Rubric	Form	Modified	Available
Federal Register CSTE Response - Core SIPP (2).pdf	Public Comments	Uploaded 2025-07-11	Repair queued
PC_202506-0920-006_071125_045141_1.pdf	Public Comments	Uploaded 2025-07-11	Available
Att B1_Public Comments.pdf	Public Comments	Uploaded 2025-06-11	Repair queued
Att L_PartnerPortalScreenShots.docx	Supplementary Document	Uploaded 2025-06-11	Repair queued
Att L_PartnerPortalScreenShots.docx	Supplementary Document	Uploaded 2025-06-11	Repair queued
Att D_PIA_Core SIPP.pdf	Supplementary Document	Uploaded 2025-06-11	Available
Att D_PIA_Core SIPP.pdf	Supplementary Document	Uploaded 2025-06-11	Repair queued
Att C_ Research Determination.docx	Supplementary Document	Uploaded 2025-06-11	Available
Att C_ Research Determination.docx	Supplementary Document	Uploaded 2025-06-11	Repair queued
Att A_Authorizing_Legislation.docx	Supplementary Document	Uploaded 2025-06-11	Available
Att A_Authorizing_Legislation.docx	Supplementary Document	Uploaded 2025-06-11	Repair queued
Attachment L_Partnes Portal Screen Shoots.pptx	Supplementary Document	Uploaded 2021-10-27	Repair queued
Attachment L_Partnes Portal Screen Shoots.pptx	Supplementary Document	Uploaded 2021-10-27	Missing upstream
Attachment D_Privacy Act Applicability CORE SIPP.pdf	Supplementary Document	Uploaded 2021-10-27	Repair queued
Attachment D_Privacy Act Applicability CORE SIPP.pdf	Supplementary Document	Uploaded 2021-10-27	Repair queued
Attachment C_Research STARSDetermination10.25.21.pdf	Supplementary Document	Uploaded 2021-10-27	Available
Attachment C_Research STARSDetermination10.25.21.pdf	Supplementary Document	Uploaded 2021-10-27	Missing upstream
Attachment B_60 Dy FRN CoreSIPP_Evaluation.pdf	Supplementary Document	Uploaded 2021-10-27	Repair queued
Attachment B_60 Dy FRN CoreSIPP_Evaluation.pdf	Supplementary Document	Uploaded 2021-10-27	Repair queued
Attachment A_Authorizing_Legislation.docx	Supplementary Document	Uploaded 2021-10-27	Available
Attachment A_Authorizing_Legislation.docx	Supplementary Document	Uploaded 2021-10-27	Repair queued
0920-1365_SSB_CoreSIPP_Final.docx	Supporting Statement B	Uploaded 2025-06-11	Available
0920-1365_SSB_CoreSIPP_Final.docx	Supporting Statement B	Uploaded 2025-06-11	Repair queued
0920-1365_SSA_CoreSIPP Final.docx	Supporting Statement A	Uploaded 2025-06-11	Repair queued
0920-1365_SSA_CoreSIPP Final.docx	Supporting Statement A	Uploaded 2025-06-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249953	Special Emphasis Reports	Form	Modified	SpecialEmphasisRpt_CoreSIPP
249953	Special Emphasis Reports	Form and Instruction	Modified	Special Emphasis Report Examples
249953	Special Emphasis Reports	Form and Instruction	Modified
249952	Hospital Discharge Injury Indicators	Form	Modified	HosDischargeInjuryIndicator_CoreSIPP
249952	Hospital Discharge Injury Indicators	Form	Modified
249951	Emergency Department Injury Indicators	Form	Modified	ERDEPTInjuryIndicator_CoreSIPP
249951	Emergency Department Injury Indicators	Form	Modified
249950	Injury Indicators	Form	Modified	DeathInjuryIndicator_CoreSIPP
249950	Injury Indicators	Form	Modified
249948	Recipient-level Group Interviews	Form	Modified	RECGroupInterview_CoreSIPP
249948	Recipient-level Group Interviews	Form	Modified
249947	Economic Indicators	Form	Modified	EcoIndicatorCostTool_CoreSIPP
249947	Economic Indicators	Form	Modified
249946	Implementation Capacity Rubric	Form	Modified	ImplementCapRubric_CoreSIPP
249946	Implementation Capacity Rubric	Form	Modified

ICR Details

OMB Control No: 0920-1365	ICR Reference No: 202506-0920-006
Status: Active	Previous ICR Reference No: 202110-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1365
Title: Program Evaluation of CDC’s Core State Injury Prevention Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/21/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/16/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	36 Months From Approved	07/31/2025
Responses	179	0	161
Time Burden (Hours)	764	0	679
Cost Burden (Dollars)	0	0	0

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Abstract: This program evaluation is intended to assess both recipient-level and program-level outcomes associated with the NCIPC's Core SIPP funded state injury prevention program. Evaluation metrics will assess injury prevention-focused infrastructure development, surveillance system development and use, and partnerships. This revision request is to add three recipients to the data collection. The estimated change in burden from the last OMB approval is an increase of 109 hours.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 77160	09/20/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 24624	06/11/2025
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Economic Indicators	0920-1365	EcoIndicatorCostTool_CoreSIPP
Emergency Department Injury Indicators	0920-1365	ERDEPTInjuryIndicator_CoreSIPP
Hospital Discharge Injury Indicators	0920-1365	HosDischargeInjuryIndicator_CoreSIPP
Implementation Capacity Rubric	0920-1365	ImplementCapRubric_CoreSIPP
Injury Indicators	0920-1365	DeathInjuryIndicator_CoreSIPP
Recipient-level Group Interviews	0920-1365	RECGroupInterview_CoreSIPP
Special Emphasis Reports	0920-21GB, 0920-1365	Special Emphasis Report Examples ,   SpecialEmphasisRpt_CoreSIPP

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ICR Summary of Burden

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	179	161	0	18	0	0
Annual Time Burden (Hours)	764	679	0	85	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This revision request is to add three recipients to the data collection. The estimated change in burden from the last OMB approval is an increase of 109 hours

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Annual Cost to Federal Government: $242,723

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/16/2025

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