OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

[PHIC] Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant

ICR 202506-0920-016 · OMB 0920-1257 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-1257 Instrument_WEB Form Modified Repair queued
Form 0920-1257 Instrument_WORD Form Modified Repair queued
Form 0920-1257 Preventive Health and Health Services Block Grant Assessment Form Modified Available
Att 1_PHHS BG Recipients.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 1_PHHS BG Recipients.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 2_Authorizing Legislation.pdf Supplementary Document Uploaded 2025-06-25 Available
Att 2_Authorizing Legislation.pdf Supplementary Document Uploaded 2025-06-25 Repair queued
Att 3_Measure Framework v1.5.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 3_Measure Framework v1.5.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 6b_Public Comment.pdf Public Comments Uploaded 2025-06-25 Available
Att 7_Privacy Impact Assessment.pdf Supplementary Document Uploaded 2025-06-25 Available
Att 7_Privacy Impact Assessment.pdf Supplementary Document Uploaded 2025-06-25 Repair queued
Att 8_Research Determination.pdf Supplementary Document Uploaded 2025-06-25 Available
Att 8_Research Determination.pdf Supplementary Document Uploaded 2025-06-25 Repair queued
Att 9_Invitation Email.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 9_Invitation Email.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 10_Reminder Email.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 10_Reminder Email.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 11_Final Reminder Email.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Att 11_Final Reminder Email.docx Supplementary Document Uploaded 2025-06-25 Repair queued
Attachment 2- Authorizing Legis 42_USC_PHHSBG_Current_2021.pdf Supplementary Document Uploaded 2022-04-25 Available
Attachment 2- Authorizing Legis 42_USC_PHHSBG_Current_2021.pdf Supplementary Document Uploaded 2022-04-25 Repair queued
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx Supplementary Document Uploaded 2022-04-25 Repair queued
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx Supplementary Document Uploaded 2022-04-25 Repair queued
Attachment 7 - Privacy Impact Assessment.pdf Supplementary Document Uploaded 2022-04-25 Repair queued
Attachment 7 - Privacy Impact Assessment.pdf Supplementary Document Uploaded 2022-04-25 Repair queued
Attachment 8- Non-Research Determination.pdf Supplementary Document Uploaded 2022-04-25 Available
Attachment 8- Non-Research Determination.pdf Supplementary Document Uploaded 2022-04-25 Repair queued
Attachment 1- List of PHHS Block Grant Grantees.docx Supplementary Document Uploaded 2022-04-25 Repair queued
Attachment 1- List of PHHS Block Grant Grantees.docx Supplementary Document Uploaded 2022-04-25 Missing upstream
30 day FRN_PHHS Block Grant Assessment Extension_2022 01 24.docx Supplementary Document Uploaded 2022-04-25 Available
30 day FRN_PHHS Block Grant Assessment Extension_2022 01 24.docx Supplementary Document Uploaded 2022-04-25 Repair queued
1257_SSB_3.27.25.docx Supporting Statement B Uploaded 2025-06-25 Available
1257_SSB_3.27.25.docx Supporting Statement B Uploaded 2025-06-25 Repair queued
1257_SSA_3.27.25.docx Supporting Statement A Uploaded 2025-06-25 Available
1257_SSA_3.27.25.docx Supporting Statement A Uploaded 2025-06-25 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
234732 Preventive Health and Health Services Block Grant Assessment Form ModifiedInstrument_WEB
234732 Preventive Health and Health Services Block Grant Assessment Form ModifiedInstrument_WORD
234732 Preventive Health and Health Services Block Grant Assessment Form Modified
ICR Details
0920-1257 202506-0920-016
Active 202204-0920-007
HHS/CDC 0920-1257
[PHIC] Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant
Revision of a currently approved collection   No
Regular
Approved without change 08/11/2025
Retrieve Notice of Action (NOA) 06/25/2025
Approved consistent with the understanding that HHS will submit a change request upon receipt of HHS guidance for revisions to Health People Topic Areas to comply with EO 14168.
  Inventory as of this Action Requested Previously Approved
08/31/2028 36 Months From Approved 08/31/2025
41 0 61
31 0 46
0 0 0
This data collection will assess select cross-cutting outputs and outcomes of the PHHS Block Grant and demonstrates the utility of the grant on a national level. Respondents include the 61 Block Grant grantees. Data will be collected using a web-based data collection instrument in fall 2019. The previous survey instrument launched in 2022 will be used. No questions have been added or deleted. Prompts were added to the Q5 and Q8 series to reduce errors.Changes to the Healthy People 2030 Topic Area 25 are expected to ensure compliance with Executive Order 14168.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  89 FR 97006 12/06/2024
90 FR 24628 06/11/2025
Yes
1
IC Title Form No. Form Name
Preventive Health and Health Services Block Grant Assessment 0920-1257, 0920-1257 Instrument_WORD ,   Instrument_WEB
  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 41 61 0 -20 0 0
Annual Time Burden (Hours) 31 46 0 -15 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
This is a revision to a collection, and the annualized burden will decrease from 46 hours to 31 hours.
$41,366
Yes Part B of Supporting Statement
    No
    No
No
No
No
No
Odion Clunis 770 488-0045 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/25/2025