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Recipient-Led Evaluation Annual Report Template
National Evaluation of the DP18-1815 Cooperative Agreement Program: Category B, Cardiovascular Disease Prevention and Management
OMB: 0920-1311
IC ID: 241434
OMB.report
HHS/CDC
OMB 0920-1311
ICR 202003-0920-010
IC 241434
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1311 can be found here:
2021-10-27 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Recipient-Led Evaluation Annual Report Template
Form and Instruction
Recipient Evalation Year 3 Effectiveness Brief
Att 6c. Cat B Rec Eval Annual Report Temp Y3.docx
Form and Instruction
Recipient Evaluation Year 4 Sustainability and Action Re
Att 6d.Cat B Rec Eval Annual Report Temp Y4.docx
Form and Instruction
Recipient Evaluation Year 5 Health Impact Statement
Att 6e.Cat B Rec Eval Annual Report Temp Y5 .docx
Form and Instruction
Att 6a. Cat Rec Eval Annual Report Temp Y1.docx
Year 1 Implementation Brief
IC Document
Att 6b.Cat B Rec Eval Annual Report Temp Y2.docx
Year 2 Efficiency Improvement Plan and Process Model
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Recipient-Led Evaluation Annual Report Template
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
n/a
Recipient Evalation Year 3 Effectiveness Brief
Att 6c. Cat B Rec Eval Annual Report Temp Y3.docx
Yes
Yes
Fillable Fileable
Form and Instruction
n/a
Recipient Evaluation Year 4 Sustainability and Action Report Guidance
Att 6d.Cat B Rec Eval Annual Report Temp Y4.docx
Yes
Yes
Fillable Fileable
Form and Instruction
n/a
Recipient Evaluation Year 5 Health Impact Statement
Att 6e.Cat B Rec Eval Annual Report Temp Y5 .docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
51
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
51
0
51
0
0
0
Annual IC Time Burden (Hours)
408
0
408
0
0
0
Annual IC Cost Burden (Dollars)
14,688
0
14,688
0
0
0
Documents for IC
Title
Document
Date Uploaded
Year 1 Implementation Brief
Att 6a. Cat Rec Eval Annual Report Temp Y1.docx
05/05/2020
Year 2 Efficiency Improvement Plan and Process Model
Att 6b.Cat B Rec Eval Annual Report Temp Y2.docx
05/05/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.