Information Collection Request

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

ICR 202305-0920-013 · OMB 0920-1412 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0920-1412 can be found here:

Forms and Documents

Document Name	Status
Form 0920-23AA Health Equity Capacity Assessment Form and Instruction	New
Form 0920-23AA Prevention Infrastructure Assessment Form and Instruction	New
Form 0920-23AA Key Informant Interview Evaluator Form and Instruction	New
Form 0920-23AA Key Informant Interview – Project Lead Form and Instruction	New
Form 0920-23AA Annual Performance Report Form and Instruction	New
Att. 5b Prevention Infrastructure Assessment Screenshots Updated.pdf Supplementary Document	2023-06-12
Att. 3b DELTA AHEAD APR Screenshots.docx.pdf Supplementary Document	2023-06-12
Att. 1 - Authorizing Legislation - FVPSA 42 USC 10414.pdf Supplementary Document	2023-06-12
SSA - DELTA AHEAD 5.16.23.docx Supporting Statement A	2023-06-12
SSB - DELTA AHEAD - 5.16.23.docx Supporting Statement B	2023-06-12

IC Document Collections

IC ID	Document Title	Status
260627	Health Equity Capacity Assessment Form and Instruction	New
260626	Prevention Infrastructure Assessment Form and Instruction	New
260625	Key Informant Interview Evaluator Form and Instruction	New
260624	Key Informant Interview – Project Lead Form and Instruction	New
260623	Annual Performance Report Form and Instruction	New

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CDC
OMB Control No	0920-1412
Type of Information Collection	New collection (Request for a new OMB Control Number)
Agency Tracking No	0920-23AA
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31