[NCIPC] DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUATION

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-23AA Att. 6a Health Equity Capacity Assessment Updated	Form and Instruction	Removed	Available
Form 0920-23AA Health Equity Capacity Assessment	Form and Instruction	Removed	Repair queued
Form 0920-1412 Prevention Infrastructure Assessment Tool - 11JUL2025	Form and Instruction	Modified	Available
Form 0920-23AA Att. 5a Prevention Infrastructure Assessment Tool Updated	Form and Instruction	Modified	Available
Form 0920-23AA Prevention Infrastructure Assessment	Form and Instruction	Modified	Missing upstream
Form 0920-1412 Key Informant Interview Protocol - Evaluator - 11JUL2025	Form and Instruction	Modified	Available
Form 0920-23AA Att. 4b Key Informant Interview Protocol - Evaluator	Form and Instruction	Modified	Available
Form 0920-23AA Key Informant Interview Evaluator	Form and Instruction	Modified	Repair queued
Form 0920-1412 Key Informant Interview Protocol - Project Lead - 11JUL2025	Form and Instruction	Modified	Available
Form 0920-23AA Att. 4a Key Informant Interview Protocol - Project Lead	Form and Instruction	Modified	Available
Form 0920-23AA Key Informant Interview – Project Lead	Form and Instruction	Modified	Missing upstream
Form 0920-1412 APR Tool - 11JUL2025	Form and Instruction	Modified	Available
Form 0920-23AA Att. 3a APR Tool	Form and Instruction	Modified	Available
Form 0920-23AA Annual Performance Report	Form and Instruction	Modified	Repair queued
Change Request Memo - 0920-1412.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-07-11	Available
Change Request Memo - 0920-1412.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-07-11	Repair queued
Att. 5b Prevention Infrastructure Assessment Screenshots Updated.pdf	Supplementary Document	Uploaded 2023-06-12	Available
Att. 5b Prevention Infrastructure Assessment Screenshots Updated.pdf	Supplementary Document	Uploaded 2023-06-12	Repair queued
Att. 3b DELTA AHEAD APR Screenshots.docx.pdf	Supplementary Document	Uploaded 2023-06-12	Available
Att. 3b DELTA AHEAD APR Screenshots.docx.pdf	Supplementary Document	Uploaded 2023-06-12	Repair queued
Att. 1 - Authorizing Legislation - FVPSA 42 USC 10414.pdf	Supplementary Document	Uploaded 2023-06-12	Available
Att. 1 - Authorizing Legislation - FVPSA 42 USC 10414.pdf	Supplementary Document	Uploaded 2023-06-12	Repair queued
SSA - DELTA AHEAD clean 0920-1412.docx	Supporting Statement A	Uploaded 2025-07-11	Available
SSA - DELTA AHEAD clean 0920-1412.docx	Supporting Statement A	Uploaded 2025-07-11	Repair queued
SSB - DELTA AHEAD clean 1412.docx	Supporting Statement B	Uploaded 2025-07-11	Available
SSB - DELTA AHEAD clean 1412.docx	Supporting Statement B	Uploaded 2025-07-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
260627	Health Equity Capacity Assessment	Form and Instruction	Removed	Att. 6a Health Equity Capacity Assessment Updated
260627	Health Equity Capacity Assessment	Form and Instruction	Removed
260626	Prevention Infrastructure Assessment	Form and Instruction	Modified	Prevention Infrastructure Assessment Tool - 11JUL2025
260626	Prevention Infrastructure Assessment	Form and Instruction	Modified	Att. 5a Prevention Infrastructure Assessment Tool Updated
260626	Prevention Infrastructure Assessment	Form and Instruction	Modified
260625	Key Informant Interview Evaluator	Form and Instruction	Modified	Key Informant Interview Protocol - Evaluator - 11JUL2025
260625	Key Informant Interview Evaluator	Form and Instruction	Modified	Att. 4b Key Informant Interview Protocol - Evaluator
260625	Key Informant Interview Evaluator	Form and Instruction	Modified
260624	Key Informant Interview – Project Lead	Form and Instruction	Modified	Key Informant Interview Protocol - Project Lead - 11JUL2025
260624	Key Informant Interview – Project Lead	Form and Instruction	Modified	Att. 4a Key Informant Interview Protocol - Project Lead
260624	Key Informant Interview – Project Lead	Form and Instruction	Modified
260623	Annual Performance Report	Form and Instruction	Modified	APR Tool - 11JUL2025
260623	Annual Performance Report	Form and Instruction	Modified	Att. 3a APR Tool
260623	Annual Performance Report	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-1412	ICR Reference No: 202507-0920-009
Status: Active	Previous ICR Reference No: 202305-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-23AA
Title: [NCIPC] DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUATION
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/11/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2026	08/31/2026	08/31/2026
Responses	42	0	52
Time Burden (Hours)	158	0	163
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of this data collection is to collect monitoring data project performance and implementation of cooperative agreement for Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Achieving Health Equity through Addressing Disparities (AHEAD). Information collected from recipients on state- and local-level will provide crucial data for performance monitoring of the cooperative agreement and will provide CDC with the capacity to respond in a timely manner to requests for information about the program from the Department of Health and Human Services (HHS), the White House, Congress, and other sources. Recipients will report progress and activity information to CDC on an annual schedule using a web-based Partners’ Portal and web-based survey tool. This Non-Substantive Change Request is submitted to make updates to questions used in OMB 0920-1412 - DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUTATION to be in accordance with EO 14168 & EO 14151. There is a net decrease of 5 burden hours.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 62859	10/17/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 37884	06/09/2023
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Annual Performance Report	0920-23AA, 0920-1412	Att. 3a APR Tool ,   APR Tool - 11JUL2025
Health Equity Capacity Assessment	0920-23AA	Att. 6a Health Equity Capacity Assessment Updated
Key Informant Interview Evaluator	0920-1412, 0920-23AA	Att. 4b Key Informant Interview Protocol - Evaluator ,   Key Informant Interview Protocol - Evaluator - 11JUL2025
Key Informant Interview – Project Lead	0920-23AA, 0920-1412	Att. 4a Key Informant Interview Protocol - Project Lead ,   Key Informant Interview Protocol - Project Lead - 11JUL2025
Prevention Infrastructure Assessment	0920-23AA, 0920-1412	Att. 5a Prevention Infrastructure Assessment Tool Updated ,   Prevention Infrastructure Assessment Tool - 11JUL2025

---

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	42	52	0	-10	0	0
Annual Time Burden (Hours)	158	163	0	-5	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: Non-Substantive Change Request is submitted to make updates to questions used in OMB 0920-1412 - DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUTATION to be in accordance with EO 14168 & EO 14151. Health Equity Capacity Assessment form is being removed. There is a net decrease of 5 burden hours.

---

Annual Cost to Federal Government: $38,832

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

---

Common Form ICR:  No

---

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: 07/11/2025

---