Preventive Health and Health Services Block Grant Assessment

[PHIC] Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant

Documents and Forms

Document Name Document Type
Form 0920-1257 Preventive Health and Health Services Block Grant Assessment Form
0920-1257 Instrument Att 4_Instrument_Word.docx Form
Att 5_Instrument_ Web version.docx Instrument _Web IC Document

Information Collection (IC) Details

IC Title:	Preventive Health and Health Services Block Grant Assessment	Agency IC Tracking Number:	0920-1257

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1257	Instrument	Att 4_Instrument_Word.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 41	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	41	-20	61
Annual IC Time Burden (Hours)	31	-15	46
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Instrument _Web	Att 5_Instrument_ Web version.docx	06/23/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.