Program Evaluation of CDC’s Core State Injury Prevention Program

Forms and Documents

Document Name	Status
Form 0920-21GB Special Emphasis Reports Form and Instruction	Modified
Form 0920-1365 Hospital Discharge Injury Indicators Form	Modified
Form 0920-1365 Emergency Department Injury Indicators Form	Modified
Form 0920-1365 Injury Indicators Form	Modified
Form 0920-1365 Recipient-level Group Interviews Form	Modified
Form 0920-1365 Economic Indicators Form	Modified
Form 0920-1365 Implementation Capacity Rubric Form	Modified
Att L_PartnerPortalScreenShots.docx Supplementary Document	2025-06-11
Att D_PIA_Core SIPP.pdf Supplementary Document	2025-06-11
Att C_ Research Determination.docx Supplementary Document	2025-06-11
Att A_Authorizing_Legislation.docx Supplementary Document	2025-06-11
Attachment L_Partnes Portal Screen Shoots.pptx Supplementary Document	2021-10-27
Attachment D_Privacy Act Applicability CORE SIPP.pdf Supplementary Document	2021-10-27
Attachment C_Research STARSDetermination10.25.21.pdf Supplementary Document	2021-10-27
Attachment B_60 Dy FRN CoreSIPP_Evaluation.pdf Supplementary Document	2021-10-27
Attachment A_Authorizing_Legislation.docx Supplementary Document	2021-10-27
0920-1365_SSB_CoreSIPP_Final.docx Supporting Statement B	2025-06-11
0920-1365_SSA_CoreSIPP Final.docx Supporting Statement A	2025-06-11

IC Document Collections

IC ID	Document Title	Status
249953	Special Emphasis Reports Form and Instruction	Modified
249952	Hospital Discharge Injury Indicators Form	Modified
249951	Emergency Department Injury Indicators Form	Modified
249950	Injury Indicators Form	Modified
249948	Recipient-level Group Interviews Form	Modified
249947	Economic Indicators Form	Modified
249946	Implementation Capacity Rubric Form	Modified

ICR Details

OMB Control No: 0920-1365	ICR Reference No: 202506-0920-006
Status: Received in OIRA	Previous ICR Reference No: 202110-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1365
Title: Program Evaluation of CDC’s Core State Injury Prevention Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/16/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2025
Responses	179	161
Time Burden (Hours)	764	679
Cost Burden (Dollars)	0	0

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Abstract: This program evaluation is intended to assess both recipient-level and program-level outcomes associated with the NCIPC's Core SIPP funded state injury prevention program. Evaluation metrics will assess injury prevention-focused infrastructure development, surveillance system development and use, and partnerships. This revision request is to add three recipients to the data collection. The estimated change in burden from the last OMB approval is an increase of 109 hours.

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Authorizing Statute(s): US Code: 42 USC 241 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:
	89 FR 77160	09/20/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 24624	06/11/2025
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
Economic Indicators	0920-1365	EcoIndicatorCostTool_CoreSIPP
Emergency Department Injury Indicators	0920-1365	ERDEPTInjuryIndicator_CoreSIPP
Hospital Discharge Injury Indicators	0920-1365	HosDischargeInjuryIndicator_CoreSIPP
Implementation Capacity Rubric	0920-1365	ImplementCapRubric_CoreSIPP
Injury Indicators	0920-1365	DeathInjuryIndicator_CoreSIPP
Recipient-level Group Interviews	0920-1365	RECGroupInterview_CoreSIPP
Special Emphasis Reports	0920-21GB, 0920-1365	Special Emphasis Report Examples ,   SpecialEmphasisRpt_CoreSIPP

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ICR Summary of Burden

	Total Request	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	179	161	0	18	0	0
Annual Time Burden (Hours)	764	679	0	85	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: This revision request is to add three recipients to the data collection. The estimated change in burden from the last OMB approval is an increase of 109 hours

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Annual Cost to Federal Government: $242,723

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 06/16/2025

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