OMB control number

Program Evaluation of CDC’s Core State Injury Prevention Program

OMB 0920-1365 · HHS/CDC.

OMB 0920-1365

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.

The latest form for Program Evaluation of CDC’s Core State Injury Prevention Program expires 2028-07-31 and is listed under ICR 202506-0920-006.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form 0920-1365 SpecialEmphasisRpt_CoreSIPP	Form
Form 0920-21GB Special Emphasis Report Examples	Form and Instruction
Form 0920-21GB Special Emphasis Reports	Form and Instruction
Form 0920-1365 HosDischargeInjuryIndicator_CoreSIPP	Form
Form 0920-1365 Hospital Discharge Injury Indicators	Form
Form 0920-1365 ERDEPTInjuryIndicator_CoreSIPP	Form
Form 0920-1365 Emergency Department Injury Indicators	Form
Form 0920-1365 DeathInjuryIndicator_CoreSIPP	Form
Form 0920-1365 Injury Indicators	Form
Form 0920-1365 RECGroupInterview_CoreSIPP	Form
Form 0920-1365 Recipient-level Group Interviews	Form
Form 0920-1365 EcoIndicatorCostTool_CoreSIPP	Form
Form 0920-1365 Economic Indicators	Form
Form 0920-1365 ImplementCapRubric_CoreSIPP	Form
Form 0920-1365 Implementation Capacity Rubric	Form
Federal Register CSTE Response - Core SIPP (2).pdf (document unavailable)	Public Comments
PC_202506-0920-006_071125_045141_1.pdf	Public Comments
Att B1_Public Comments.pdf (document unavailable)	Public Comments
Att L_PartnerPortalScreenShots.docx	Supplementary Document
Att L_PartnerPortalScreenShots.docx	Supplementary Document
Att D_PIA_Core SIPP.pdf	Supplementary Document
Att D_PIA_Core SIPP.pdf	Supplementary Document
Att C_ Research Determination.docx	Supplementary Document
Att C_ Research Determination.docx	Supplementary Document
Att A_Authorizing_Legislation.docx	Supplementary Document
Att A_Authorizing_Legislation.docx	Supplementary Document
Attachment L_Partnes Portal Screen Shoots.pptx	Supplementary Document
Attachment D_Privacy Act Applicability CORE SIPP.pdf	Supplementary Document
Attachment C_Research STARSDetermination10.25.21.pdf	Supplementary Document
Attachment C_Research STARSDetermination10.25.21.pdf	Supplementary Document
Attachment B_60 Dy FRN CoreSIPP_Evaluation.pdf	Supplementary Document
Attachment A_Authorizing_Legislation.docx	Supplementary Document
Attachment A_Authorizing_Legislation.docx	Supplementary Document
0920-1365_SSB_CoreSIPP_Final.docx	Supporting Statement B
0920-1365_SSB_CoreSIPP_Final.docx	Supporting Statement B
0920-1365_SSA_CoreSIPP Final.docx	Supporting Statement A
0920-1365_SSA_CoreSIPP Final.docx	Supporting Statement A
Special Emphasis Reports	Form
Special Emphasis Reports	Form and Instruction
Special Emphasis Reports	Form and Instruction
Hospital Discharge Injury Indicators	Form
Hospital Discharge Injury Indicators	Form
Emergency Department Injury Indicators	Form
Emergency Department Injury Indicators	Form
Injury Indicators	Form
Injury Indicators	Form
Recipient-level Group Interviews	Form
Recipient-level Group Interviews	Form
Economic Indicators	Form
Economic Indicators	Form
Implementation Capacity Rubric	Form
Implementation Capacity Rubric	Form

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Concluded	Action
202506-0920-006	Revision of a currently approved collection	2025-06-16
202110-0920-010	New collection (Request for a new OMB Control Number)	2021-10-29		Approved without change

OMB Details

Implementation Capacity Rubric

Federal Enterprise Architecture: Health - Public Health Monitoring

Information collection instruments
Form	Name	Electronic access	Type
Form 0920-1365	ImplementCapRubric_CoreSIPP	Fillable Fileable	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.