An Assessment of the State Public Health Actions (“1305”) Program

Forms and Documents

Document Name	Status
State Synergy Survey Form	New
Att 7_IRB Approval Letter_5-6-16.PDF Supplementary Document	2016-06-15
Att 6c_Reminder Email Template_5-6-16.docx Supplementary Document	2016-06-15
Att 6b_Participant Email Template_5-6-16.docx Supplementary Document	2016-06-15
Att 6a_Advance Notice Blast Email Template_5-6-16.docx Supplementary Document	2016-06-15
Att 4_Evaluation Questions, Indicators, and Synergy Survey Topics_5-23-16.docx Supplementary Document	2016-06-15
Att 3_State Public Health Actions 1305 Logic Model_5-5-16.docx Supplementary Document	2016-06-15
Att 2b_public comment 05032016.pdf Supplementary Document	2016-06-15
Att 2a_Federal Register Notice.pdf Supplementary Document	2016-06-15
Att 1_Authorizing Legislation PHSA.doc Supplementary Document	2016-06-15
Part B_16RZ_5-26-16.docx Supporting Statement B	2016-06-15
Part A_16RZ_6-13-2016.docx Supporting Statement A	2016-06-15

IC Document Collections

IC ID	Document Title	Status
222004	State Synergy Survey Form	New

ICR Details

OMB Control No: 0920-1152	ICR Reference No: 201606-0920-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 16RZ
Title: An Assessment of the State Public Health Actions (“1305”) Program
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: 01/17/2017
	Date Received in OIRA: 06/27/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved
Responses	408	0	0
Time Burden (Hours)	306	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The State Public Health Actions cooperative agreement is structured to encourage the coordination of chronic disease programs at the state level. This information collection is designed to improve understanding of how state programs are implementing the program model.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: PHSA
  

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:
	81 FR 11796	03/07/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 41539	06/27/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
State Synergy Survey	none	State Public Health Actions 1305 State Synergy Survey

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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	408	0	0	408	0	0
Annual Time Burden (Hours)	306	0	0	306	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: Submission is a New ICR

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Annual Cost to Federal Government: $21,464

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]? No

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: 06/27/2016

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