Communities Putting Prevention to Work

Forms and Documents

Document Name	Status
Form 4 Application for Pacific Islands Supplemental Funding Form and Instruction	New
Form 3 Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control and Behavioral Risk Factor Surveillance Form and Instruction	Modified
0920-0820 Change Justification #2 9-16-09.doc Justification for No Material/Nonsubstantive Change	2009-09-17
0920-0820 Change Justification 9-15-09.doc Justification for No Material/Nonsubstantive Change	2009-09-15
0920-0820 Rev. _SS_9_16_2009.doc Supporting Statement A	2009-09-17

IC Document Collections

IC ID	Document Title	Status
190710	Application for Pacific Islands Supplemental Funding Form and Instruction	New
190673	Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control and Behavioral Risk Factor Surveillance Form and Instruction	Modified
190672	Application for Community Approaches to Chronic Disease Prevention and Control Other-Application	Unchanged
190671	LOI for Community Approaches to Chronic Disease Prevention and Control Other-Letter of Intent	Unchanged

ICR Details

OMB Control No: 0920-0820	ICR Reference No: 200909-0920-009
Status: Historical Active	Previous ICR Reference No: 200909-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Communities Putting Prevention to Work
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/15/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/17/2009
	Date Received in OIRA: 09/17/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	12/31/2009	12/31/2009
Responses	529	0	531
Time Burden (Hours)	12,640	0	12,780
Cost Burden (Dollars)	0	0	0

---

Abstract: The Centers for Disease Control and Prevention (CDC) seeks approval to support intensive community approaches to chronic disease prevention and control in selected communities to achieve prevention outcomes related to increased physical activity, improved nutrition, decreased overweight/obesity prevalence, decreased smoking prevalence and teen smoking initiation; and decreased exposure to secondhand smoke.

Emergency Justfication: An emergency clearance is requested based on the time-sensitive nature of activities to be funded through this ARRA clearance.

---

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

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

Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
LOI for Community Approaches to Chronic Disease Prevention and Control
Application for Community Approaches to Chronic Disease Prevention and Control
Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control and Behavioral Risk Factor Surveillance	3	Supplemental Funds Application
Application for Pacific Islands Supplemental Funding	4	Application for Pacific Islands Supplemental Funding

---

ICR Summary 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	529	531	0	-2	0	0
Annual Time Burden (Hours)	12,640	12,780	0	-140	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to: Changing Forms

Short Statement: This is a new data collection.

---

Annual Cost to Federal Government: $222,667

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

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: 09/17/2009

---