Information Collection

Preventive Health and Health Services Block Grant Assessment

IC 234732 under ICR 202506-0920-014 · OMB 0920-1257.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1257 can be found here:

Documents and Forms

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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1257				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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Instrument _Web		06/23/2025

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

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