Monitoring and Reporting System for the State Public Health Actions Cooperative Agreements

Forms and Documents

Document Name	Status
Enhanced Awardees Annual Evaluation Plan Form	New
Enhanced Awardees Annual Budget Form	New
Enhanced Awardees Annual Workplan Form	New
Enhanced Awardees Initial Evaluation Form	New
Enhanced Awardees Initial Budget Form	New
Enhanced Awardees Initial Workplan Form	New
Basic Awardees Annual Evaluation Plan Form	New
Basic Awardees Annual Budget Form	New
Basic Awardees Annual Work Plan Form	New
Basic Awardees Initial Evaluation Plan Form	New
Basic Awardees Initial Budget Form	New
Basic Awardees Initial Work Plan Form	New
Att 1c. PHSA_Research and Investigation.doc Supplementary Document	2014-11-03
Att 1a. PHSA_Preventive Health Services.pdf Supplementary Document	2014-11-03
Att 1b. ACA_PPHF.pdf Supplementary Document	2014-11-03
Att 4e. Screen Shots of FTP Site.docx Supplementary Document	2014-11-03
Att 3b. Summary of Public Comments.doc Supplementary Document	2014-11-03
Att 3a. 60-day FRN 11 25 2013.pdf Supplementary Document	2014-11-03
Att 2. List of awardees.docx Supplementary Document	2014-11-03
SS Part B_10 29 2014.docx Supporting Statement B	2014-11-03
SS Part A_10 29 2014.docx Supporting Statement A	2014-11-03

IC Document Collections

IC ID	Document Title	Status
213721	Enhanced Awardees Annual Evaluation Plan Form	New
213720	Enhanced Awardees Annual Budget Form	New
213718	Enhanced Awardees Annual Workplan Form	New
213717	Enhanced Awardees Initial Evaluation Form	New
213716	Enhanced Awardees Initial Budget Form	New
213715	Enhanced Awardees Initial Workplan Form	New
213714	Basic Awardees Annual Evaluation Plan Form	New
213713	Basic Awardees Annual Budget Form	New
213712	Basic Awardees Annual Work Plan Form	New
213711	Basic Awardees Initial Evaluation Plan Form	New
213710	Basic Awardees Initial Budget Form	New
213709	Basic Awardees Initial Work Plan Form	New

ICR Details

OMB Control No: 0920-1059	ICR Reference No: 201411-0920-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 14CP
Title: Monitoring and Reporting System for the State Public Health Actions Cooperative Agreements
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/26/2015
	Date Received in OIRA: 11/14/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2018	36 Months From Approved
Responses	204	0	0
Time Burden (Hours)	665	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC requests OMB approval for three years to collect performance monitoring and evaluation information from grantees funded through the new State Public Health Actions program.

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Authorizing Statute(s): US Code: 42 USC 247b Name of Law: PHSA
   US Code: 42 USC 241 Name of Law: PHSA
   PL: Pub.L. 111 - 148 4002 Name of Law: ACA
  

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:
	78 FR 70300	11/25/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 65972	11/06/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 12

IC Title	Form No.	Form Name
Enhanced Awardees Annual Evaluation Plan	none	Enhanced Awardees Annual Evaluation Plan
Basic Awardees Initial Evaluation Plan	none	Basic Evaluation Plan
Basic Awardees Annual Budget	none	Basic Annual Budget
Enhanced Awardees Initial Workplan	none	Enhanced Awardees Initial Workplan
Enhanced Awardees Initial Evaluation	none	Enhanced Awardees Initial Evaluation
Basic Awardees Initial Budget	none	Initial Budget
Basic Awardees Annual Work Plan	none	Basic Annual Workplan
Basic Awardees Annual Evaluation Plan	none	Basic Awardees Annual Evaluation Plan
Enhanced Awardees Annual Budget	none	Enhanced Awardees Annual Budget
Basic Awardees Initial Work Plan	none	Work Plan
Enhanced Awardees Initial Budget	none	Enhanced Awardees Initial Budget
Enhanced Awardees Annual Workplan	none	Enhanced Awardees Annual Workplan

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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	204	0	0	204	0	0
Annual Time Burden (Hours)	665	0	0	665	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: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $229,659

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

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]? Yes

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? Uncollected

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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: 11/14/2014

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