[PHIC] Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant

Forms and Documents

Document Name	Status
Form 0920-1257 Preventive Health and Health Services Block Grant Assessment Form	Modified
Att 1_PHHS BG Recipients.docx Supplementary Document	2025-06-23
Att 11_Final Reminder Email.docx Supplementary Document	2025-06-23
Att 9_Invitation Email.docx Supplementary Document	2025-06-23
Att 3_Measure Framework v1.5.docx Supplementary Document	2025-06-23
Att 7_Privacy Impact Assessment.pdf Supplementary Document	2025-06-23
Att 8_Research Determination.pdf Supplementary Document	2025-06-23
Att 2_Authorizing Legislation.pdf Supplementary Document	2025-06-23
Attachment 2- Authorizing Legis 42_USC_PHHSBG_Current_2021.pdf Supplementary Document	2022-04-25
Attachment 3- PHHS Block Grant Measurement Framework_Vers1.5 updated cz.docx Supplementary Document	2022-04-25
Attachment 7 - Privacy Impact Assessment.pdf Supplementary Document	2022-04-25
Attachment 8- Non-Research Determination.pdf Supplementary Document	2022-04-25
Attachment 1- List of PHHS Block Grant Grantees.docx Supplementary Document	2022-04-25
30 day FRN_PHHS Block Grant Assessment Extension_2022 01 24.docx Supplementary Document	2022-04-25
1257_SSB_3.27.25.docx Supporting Statement B	2025-06-23
1257_SSA_3.27.25.docx Supporting Statement A	2025-06-23

IC Document Collections

IC ID	Document Title	Status
234732	Preventive Health and Health Services Block Grant Assessment Form	Modified

ICR Details

OMB Control No: 0920-1257	ICR Reference No: 202506-0920-014
Status: Received in OIRA	Previous ICR Reference No: 202204-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1257
Title: [PHIC] Assessment of Outcomes Associated with the Preventive Health and Health Services Block Grant
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/23/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2025
Responses	41	61
Time Burden (Hours)	31	46
Cost Burden (Dollars)	0	0

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Abstract: This data collection will assess select cross-cutting outputs and outcomes of the PHHS Block Grant and demonstrates the utility of the grant on a national level. Respondents include the 61 Block Grant grantees. Data will be collected using a web-based data collection instrument in fall 2019.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

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 97006	12/06/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 24628	06/11/2025
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Preventive Health and Health Services Block Grant Assessment	0920-1257	Instrument

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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	41	61	0	-20	0	0
Annual Time Burden (Hours)	31	46	0	-15	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is an extension of an existing collection for 31 burden hours.

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Annual Cost to Federal Government: $32,455

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 06/23/2025

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