Site-Specific Evaluation (post-intervention evaluation only)

A Site-Specific Modular Evaluation Instrument for Behavior Outcome Measurement

Documents and Forms

Document Name Document Type
Site-Specific Evaluation (post-intervention evaluation only) Form and Instruction
Additional Optional Survey Modules on Demographics, QOL, Attachment G Additional Modules.doc Form and Instruction
CEEPM Module - Contaminant Group, Env Media, and Env Pat Attachment F3. PROPOSED CEEPM Reference Modules.doc Form and Instruction
Attachment L2 Sample Cover Letter for Post.doc Sample Letter for Post-Intervention Evaluation IC Document
Attachment M Sample Interviewer Scripts.doc Sample Interviewer Scripts IC Document

Information Collection (IC) Details

IC Title:	Site-Specific Evaluation (post-intervention evaluation only)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Additional Optional Survey Modules on Demographics, QOL, Stress, Intention to Change, Knowledge and Beliefs	Attachment G Additional Modules.doc		No	No	Paper Only
Form and Instruction	None	CEEPM Module - Contaminant Group, Env Media, and Env Pathway	Attachment F3. PROPOSED CEEPM Reference Modules.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-19-0001 Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 59 FR 67085

Number of Respondents: 10,750	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,750	10,750
Annual IC Time Burden (Hours)	3,583	3,583
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Sample Letter for Post-Intervention Evaluation	Attachment L2 Sample Cover Letter for Post.doc	06/22/2007
Sample Interviewer Scripts	Attachment M Sample Interviewer Scripts.doc	06/22/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.