Workplan Start and Advisory Committee Quesions

Form Approved

OMB No 0920-0106

Expiration 2/29/2024

Attachment C: Work Plan Start and Advisory Committee Questions

Workplan Budget Data Collection Instrument

General Information

1. Workplan name: [Short Text]

2. Recipient name: Prepopulated

3. Fiscal Year: *Choose one ☐2023 ☐2024 ☐2025 ☐2026 ☐2027

Associated Budget

Budget Name: [Auto-generates]

4. Recipient name: Prepopulated

Workplan name: [Short Text]

Fiscal Year: *Choose one ☐2023 ☐2024 ☐2025 ☐2026 ☐2027

Allocation Table: [Short Text]

1. Basic Administrative Cost*: [Short Text]

Q1. Are your receiving Direct Assistance?* ☐No ☐ Yes

2. Direct Assistance Amount: (Enter amount if you answered Yes to Q1, else enter 0)*: [Short Text]

3. Total Available for Program Allocation (Basic)*: [Short Text]

4. Total Annual Basic Allocation for the current FY (A + B + C) This amount MUST match your Annual Basic Allocation from the Allocation Table*: [Short Text]

Sex Offense Set-Aside Allocation

5. Sex Offense Administrative Cost*: [Short Text]

6. Total Available for Program Allocation (Sex Offense)*: [Short Text]

7. Total Annual Sex Offense Set-Aside Allocation for the current FY (E + F)*: [Short Text]

G NOTE: This amount MUST match your Annual Sex Offense Set-Aside Allocation from the Allocation Table.

8. Total FY Allocation (D+G)*: [Short Text]

H Note: This amount MUST match I: Total FY Award from the Allocation Table.

9. Total FY Award (Copy from Allocation Table)*: [Short Text]

Advisory Committee Members Data Collection Instrument

Recipient name*: Prepopulated

Contact name*: *Choose one [options pulled from recipient contact list]

Title*: [Short Text]

1a. Is Committee Chair Lead Health Official?* ☐ No ☐ Yes

1b. If No, Please Enter Lead Health Official (Required if you answered No to 1A else leave blank)* [Short Text]

Year First Joined Advisory Committee*: [Short Text]

Relevant Constituencies*

Community Based Organization: ☐ No ☐ Yes

Community Resident: ☐No ☐Yes

County and/or Local Health Department: ☐No ☐Yes

Minority Related Organization: ☐No ☐Yes

Schools of Public Health: ☐No ☐Yes

Other: ☐No☐ Yes

If Other, Please Specify: [Short Text]

*Note: These questions must be answered for each individually listed advisory committee member.

Advisory Committee Meeting Data Collection Instrument

General Details*

Title of Meeting*: [Short Text]

Recipient Name: Prepopulated

Date of Meeting*: [Short Text]

Federal Fiscal Year(s) of the Work Plan discussed at this meeting. Enter 4-digit years only (For example, 2022. Do NOT use other formats such as 22 or FY 22.)*: [Short Text]

1A. Type of Meeting*: Choose One ☐ First Advisory Committee Meeting ☐ Second Advisory Committee Meeting ☐ Other Advisory Committee Meeting ☐ Public Hearing☐ Other Advisory Committee Meeting ☐ Public Hearing

Please list all the committee members who attended this meeting*: [Short Text]

2A. Who chaired this meeting*? [Short Text]

2B. Is this person the official Chair of the Advisory Committee (If the person chaired this meeting under delegated authority from the Chair of the Advisory Committee, select No.)* Choose one ☐Yes ☐No

1B. How was the public invited to the Public Hearing? Select all that apply (Required if 1A. "Type of meeting" is "Public Hearing")

☐Email Announcement ☐Flyers ☐Phone Calls ☐Mass Text Message ☐In Person

☐Press Release ☐Website ☐Mailings ☐Radio ☐TV ☐Social Media ☐Other

If Other, Please Specify: [Short Text]

1C. How was the draft Work Plan made available for public viewing? Select all that apply. (Required if 1A. "Type of meeting" is "Public Hearing")

☐Email Announcement ☐Flyers ☐Phone Calls ☐Mass Text Message ☐In Person

☐Press Release ☐Website ☐Mailings ☐Radio ☐TV ☐Social Media ☐Other

If Other, Please Specify: [Short Text]

Document Location: Please upload the minutes of this meeting. [option to upload file(s)]

The public reporting burden of this collection of information is estimated to average 2 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, HS 21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-0106)