Information Collection Request

[NCHHSTP] Evaluation of Safe Spaces in CDC-directly funded Community-based Organizations (CBOs)

ICR 202212-0920-002 · OMB 0920-1403 · Received in OIRA

Forms and Documents

Document Name	Status
Form 0920- Staff Interview Form and Instruction	New
Form 0920- Client Survey (Participant) Form	New
Form 0920 Eligibility Screener Form and Instruction	New
Privacy Act Checklist.docx Supplementary Document	2023-01-06
Att 1_Section 301 of the Public Health Service Act.docx Supplementary Document	2023-01-06
SS B_121922.docx Supporting Statement B	2023-01-06
SS A_121922.docx Supporting Statement A	2023-01-06

IC Document Collections

IC ID	Document Title	Status
257787	Staff Interview Form and Instruction	New
257786	Client Survey (Participant) Form	New
257785	Eligibility Screener Form and Instruction	New

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CDC
OMB Control No	0920-1403
Type of Information Collection	New collection (Request for a new OMB Control Number)
Agency Tracking No	0920-22IJ
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31