OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

[NCIPC] DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUATION

ICR 202507-0920-009 · OMB 0920-1412 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-23AA Att. 6a Health Equity Capacity Assessment Updated Form and Instruction Removed Available
Form 0920-23AA Health Equity Capacity Assessment Form and Instruction Removed Missing upstream
Form 0920-1412 Prevention Infrastructure Assessment Tool - 11JUL2025 Form and Instruction Modified Available
Form 0920-23AA Att. 5a Prevention Infrastructure Assessment Tool Updated Form and Instruction Modified Available
Form 0920-23AA Prevention Infrastructure Assessment Form and Instruction Modified Repair queued
Form 0920-1412 Key Informant Interview Protocol - Evaluator - 11JUL2025 Form and Instruction Modified Available
Form 0920-23AA Att. 4b Key Informant Interview Protocol - Evaluator Form and Instruction Modified Available
Form 0920-23AA Key Informant Interview Evaluator Form and Instruction Modified Repair queued
Form 0920-1412 Key Informant Interview Protocol - Project Lead - 11JUL2025 Form and Instruction Modified Available
Form 0920-23AA Att. 4a Key Informant Interview Protocol - Project Lead Form and Instruction Modified Available
Form 0920-23AA Key Informant Interview – Project Lead Form and Instruction Modified Repair queued
Form 0920-1412 APR Tool - 11JUL2025 Form and Instruction Modified Available
Form 0920-23AA Att. 3a APR Tool Form and Instruction Modified Available
Form 0920-23AA Annual Performance Report Form and Instruction Modified Repair queued
Change Request Memo - 0920-1412.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-07-11 Available
Change Request Memo - 0920-1412.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-07-11 Repair queued
Att. 5b Prevention Infrastructure Assessment Screenshots Updated.pdf Supplementary Document Uploaded 2023-06-12 Available
Att. 5b Prevention Infrastructure Assessment Screenshots Updated.pdf Supplementary Document Uploaded 2023-06-12 Repair queued
Att. 3b DELTA AHEAD APR Screenshots.docx.pdf Supplementary Document Uploaded 2023-06-12 Available
Att. 3b DELTA AHEAD APR Screenshots.docx.pdf Supplementary Document Uploaded 2023-06-12 Repair queued
Att. 1 - Authorizing Legislation - FVPSA 42 USC 10414.pdf Supplementary Document Uploaded 2023-06-12 Available
Att. 1 - Authorizing Legislation - FVPSA 42 USC 10414.pdf Supplementary Document Uploaded 2023-06-12 Repair queued
SSA - DELTA AHEAD clean 0920-1412.docx Supporting Statement A Uploaded 2025-07-11 Available
SSA - DELTA AHEAD clean 0920-1412.docx Supporting Statement A Uploaded 2025-07-11 Missing upstream
SSB - DELTA AHEAD clean 1412.docx Supporting Statement B Uploaded 2025-07-11 Available
SSB - DELTA AHEAD clean 1412.docx Supporting Statement B Uploaded 2025-07-11 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
260627 Health Equity Capacity Assessment Form and Instruction RemovedAtt. 6a Health Equity Capacity Assessment Updated
260627 Health Equity Capacity Assessment Form and Instruction Removed
260626 Prevention Infrastructure Assessment Form and Instruction ModifiedPrevention Infrastructure Assessment Tool - 11JUL2025
260626 Prevention Infrastructure Assessment Form and Instruction ModifiedAtt. 5a Prevention Infrastructure Assessment Tool Updated
260626 Prevention Infrastructure Assessment Form and Instruction Modified
260625 Key Informant Interview Evaluator Form and Instruction ModifiedKey Informant Interview Protocol - Evaluator - 11JUL2025
260625 Key Informant Interview Evaluator Form and Instruction ModifiedAtt. 4b Key Informant Interview Protocol - Evaluator
260625 Key Informant Interview Evaluator Form and Instruction Modified
260624 Key Informant Interview – Project Lead Form and Instruction ModifiedKey Informant Interview Protocol - Project Lead - 11JUL2025
260624 Key Informant Interview – Project Lead Form and Instruction ModifiedAtt. 4a Key Informant Interview Protocol - Project Lead
260624 Key Informant Interview – Project Lead Form and Instruction Modified
260623 Annual Performance Report Form and Instruction ModifiedAPR Tool - 11JUL2025
260623 Annual Performance Report Form and Instruction ModifiedAtt. 3a APR Tool
260623 Annual Performance Report Form and Instruction Modified
ICR Details
0920-1412 202507-0920-009
Active 202305-0920-013
HHS/CDC 0920-23AA
[NCIPC] DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUATION
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 07/14/2025
Retrieve Notice of Action (NOA) 07/11/2025
  Inventory as of this Action Requested Previously Approved
08/31/2026 08/31/2026 08/31/2026
42 0 52
158 0 163
0 0 0
The purpose of this data collection is to collect monitoring data project performance and implementation of cooperative agreement for Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) Achieving Health Equity through Addressing Disparities (AHEAD). Information collected from recipients on state- and local-level will provide crucial data for performance monitoring of the cooperative agreement and will provide CDC with the capacity to respond in a timely manner to requests for information about the program from the Department of Health and Human Services (HHS), the White House, Congress, and other sources. Recipients will report progress and activity information to CDC on an annual schedule using a web-based Partners’ Portal and web-based survey tool. This Non-Substantive Change Request is submitted to make updates to questions used in OMB 0920-1412 - DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUTATION to be in accordance with EO 14168 & EO 14151. There is a net decrease of 5 burden hours.
None
None
Not associated with rulemaking
  87 FR 62859 10/17/2022
88 FR 37884 06/09/2023
Yes
  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 42 52 0 -10 0 0
Annual Time Burden (Hours) 158 163 0 -5 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
Non-Substantive Change Request is submitted to make updates to questions used in OMB 0920-1412 - DELTA Achieving Health Equity through Addressing Disparities (AHEAD) COOPERATIVE AGREEMENT EVALUTATION to be in accordance with EO 14168 & EO 14151. Health Equity Capacity Assessment form is being removed. There is a net decrease of 5 burden hours.
$38,832
No
    No
    No
No
No
No
No
Jeffrey Zirger 404 639-7118 [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.
07/11/2025