OMB control number

Program Evaluation of CDC’s Core State Injury Prevention Program

OMB 0920-1365 · HHS/CDC.

OMB 0920-1365

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.

The latest form for Program Evaluation of CDC’s Core State Injury Prevention Program expires 2028-07-31 and can be found here.

Latest Forms, Documents, and Supporting Material

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

All Historical Document Collections

202506-0920-006	Revision of a currently approved collection	2025-06-16
202110-0920-010 Approved without change	New collection (Request for a new OMB Control Number)	2021-10-29

OMB Details

Implementation Capacity Rubric

Federal Enterprise Architecture: Health - Public Health Monitoring

Form 0920-1365

ImplementCapRubric_CoreSIPP

Fillable Fileable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.