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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1257 Instrument_WEB	Form	Modified	Available
Form 0920-1257 Instrument_WORD	Form	Modified	Available
Form 0920-1257 Preventive Health and Health Services Block Grant Assessment	Form	Modified	Available
Att 1_PHHS BG Recipients.docx	Supplementary Document	Uploaded 2025-06-25	Available
Att 1_PHHS BG Recipients.docx	Supplementary Document	Uploaded 2025-06-25	Repair queued
Att 2_Authorizing Legislation.pdf	Supplementary Document	Uploaded 2025-06-25	Available
Att 2_Authorizing Legislation.pdf	Supplementary Document	Uploaded 2025-06-25	Repair queued
Att 3_Measure Framework v1.5.docx	Supplementary Document	Uploaded 2025-06-25	Available
Att 3_Measure Framework v1.5.docx	Supplementary Document	Uploaded 2025-06-25	Missing upstream
Att 6b_Public Comment.pdf	Public Comments	Uploaded 2025-06-25	Available
Att 7_Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2025-06-25	Available
Att 7_Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2025-06-25	Repair queued
Att 8_Research Determination.pdf	Supplementary Document	Uploaded 2025-06-25	Available
Att 8_Research Determination.pdf	Supplementary Document	Uploaded 2025-06-25	Repair queued
Att 9_Invitation Email.docx	Supplementary Document	Uploaded 2025-06-25	Available
Att 9_Invitation Email.docx	Supplementary Document	Uploaded 2025-06-25	Repair queued
Att 10_Reminder Email.docx	Supplementary Document	Uploaded 2025-06-25	Available
Att 10_Reminder Email.docx	Supplementary Document	Uploaded 2025-06-25	Repair queued
Att 11_Final Reminder Email.docx	Supplementary Document	Uploaded 2025-06-25	Available
Att 11_Final Reminder Email.docx	Supplementary Document	Uploaded 2025-06-25	Repair queued
Attachment 2- Authorizing Legis 42_USC_PHHSBG_Current_2021.pdf	Supplementary Document	Uploaded 2022-04-25	Available
Attachment 2- Authorizing Legis 42_USC_PHHSBG_Current_2021.pdf	Supplementary Document	Uploaded 2022-04-25	Repair queued
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx	Supplementary Document	Uploaded 2022-04-25	Available
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx	Supplementary Document	Uploaded 2022-04-25	Repair queued
Attachment 7 - Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2022-04-25	Available
Attachment 7 - Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2022-04-25	Repair queued
Attachment 8- Non-Research Determination.pdf	Supplementary Document	Uploaded 2022-04-25	Available
Attachment 8- Non-Research Determination.pdf	Supplementary Document	Uploaded 2022-04-25	Missing upstream
Attachment 1- List of PHHS Block Grant Grantees.docx	Supplementary Document	Uploaded 2022-04-25	Available
Attachment 1- List of PHHS Block Grant Grantees.docx	Supplementary Document	Uploaded 2022-04-25	Repair queued
30 day FRN_PHHS Block Grant Assessment Extension_2022 01 24.docx	Supplementary Document	Uploaded 2022-04-25	Available
30 day FRN_PHHS Block Grant Assessment Extension_2022 01 24.docx	Supplementary Document	Uploaded 2022-04-25	Repair queued
1257_SSB_3.27.25.docx	Supporting Statement B	Uploaded 2025-06-25	Available
1257_SSB_3.27.25.docx	Supporting Statement B	Uploaded 2025-06-25	Repair queued
1257_SSA_3.27.25.docx	Supporting Statement A	Uploaded 2025-06-25	Available
1257_SSA_3.27.25.docx	Supporting Statement A	Uploaded 2025-06-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
234732	Preventive Health and Health Services Block Grant Assessment	Form	Modified	Instrument_WEB
234732	Preventive Health and Health Services Block Grant Assessment	Form	Modified	Instrument_WORD
234732	Preventive Health and Health Services Block Grant Assessment	Form	Modified

ICR Details

OMB Control No: 0920-1257	ICR Reference No: 202506-0920-016
Status: Active	Previous ICR Reference No: 202204-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1257
Title: [PHIC] Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant
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: 08/11/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/25/2025
Terms of Clearance: Approved consistent with the understanding that HHS will submit a change request upon receipt of HHS guidance for revisions to Health People Topic Areas to comply with EO 14168.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2028	36 Months From Approved	08/31/2025
Responses	41	0	61
Time Burden (Hours)	31	0	46
Cost Burden (Dollars)	0	0	0

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Abstract: This data collection will assess select cross-cutting outputs and outcomes of the PHHS Block Grant and demonstrates the utility of the grant on a national level. Respondents include the 61 Block Grant grantees. Data will be collected using a web-based data collection instrument in fall 2019. The previous survey instrument launched in 2022 will be used. No questions have been added or deleted. Prompts were added to the Q5 and Q8 series to reduce errors.Changes to the Healthy People 2030 Topic Area 25 are expected to ensure compliance with Executive Order 14168.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

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 97006	12/06/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 24628	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: 1

table that charts list of burden

IC Title	Form No.	Form Name
Preventive Health and Health Services Block Grant Assessment	0920-1257, 0920-1257	Instrument_WORD ,   Instrument_WEB

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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	41	61	0	-20	0	0
Annual Time Burden (Hours)	31	46	0	-15	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a revision to a collection, and the annualized burden will decrease from 46 hours to 31 hours.

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Annual Cost to Federal Government: $41,366

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 06/25/2025

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