OMB control number

Evaluation of Public Health AmeriCorps

OMB 3045-0199 · CNCS.

OMB 3045-0199

This information collection includes a survey of Public Health AmeriCorps (PHA) members, a survey of PHA grantees and a PHA grantee training and technical assistance form, and questions for PHA grantees who choose to participate in focus groups, to allow AmeriCorps to evaluate the success of PHA in meeting its goals of addressing public health needs and developing the next generation of public health leaders.

The latest form for Evaluation of Public Health AmeriCorps expires 2027-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 06 Training and TA Form Form and Instruction
Form 06 Training and TA Form Form and Instruction
Form 02 Grantee Survey Form and Instruction
Form 02 Grantee Survey Form and Instruction
Form 01 Early Exit Survey Form and Instruction
Form 01 Early Exit Survey Form and Instruction
Form 01 Member Alumni Survey Form and Instruction
Form 01 Member Alumni Survey Form and Instruction
0199- Nonsub Justification.docx Justification for No Material/Nonsubstantive Change
0199- Nonsub Justification.docx Justification for No Material/Nonsubstantive Change
PHA EVAL Justification of Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change
PHA EVAL Justification of Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change
30-Day Notice_02-06-24.pdf Supplementary Document
30-Day Notice_02-06-24.pdf Supplementary Document
60-Day PHA Evaluation.pdf Supplementary Document
60-Day PHA Evaluation.pdf Supplementary Document
42 U.S.C. 12639.pdf Supplementary Document
42 U.S.C. 12639.pdf Supplementary Document
EO 13996.pdf Supplementary Document
EO 13996.pdf Supplementary Document
3045-NEW PHA Member Outcome Surveys_SSB_FINAL.docx Supporting Statement B
3045-NEW PHA Member Outcome Surveys_SSB_FINAL.docx Supporting Statement B
3045-NEW PHA Member outcome Surveys_SSA_FINAL.docx Supporting Statement A
3045-NEW PHA Member outcome Surveys_SSA_FINAL.docx Supporting Statement A
Partner Interview Other-Interview Questions
Early Exit Interview Other-Interview Questions
Grantee Focus Group Other-Focus Group Questions
Training and TA Form Form and Instruction
Training and TA Form Form and Instruction
Grantee Survey Form and Instruction
Grantee Survey Form and Instruction
Early Exit Survey Form and Instruction
Early Exit Survey Form and Instruction
Member Alumni Survey Form and Instruction
Member Alumni Survey Form and Instruction

All Historical Document Collections

202503-3045-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2025-03-26
202406-3045-001	No material or nonsubstantive change to a currently approved collection	2024-06-05
202311-3045-001 Approved with change	New collection (Request for a new OMB Control Number)	2024-02-06

OMB Details

Member Alumni Survey

Federal Enterprise Architecture: Community and Social Services - Social Services

Form 01

Revised Member Alumni Survey and Early Exit Survey

www.americorps.gov

Form and instruction

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