Information Collection

Phase II 1, 3, 6 months forms

IC 191374 under ICR 200911-0920-006 · OMB 0920-0843.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0843 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Phase II 1, 3, 6 months forms Form and Instruction
1 Phase I Section Foreman Form Attachment 6 - Phase I Section Foreman Form.doc Form and Instruction
2 Phase I Baseline Form Attachment 7 - Phase I Baseline Form.doc Form
3 Phase I 1 month form Attachment 8 - Phase I 1 month form.doc Form
4 Phase I Focus Group Questions Moderator Guide Attachment 9 - Phase I Focus Group Questions.doc Form and Instruction
5 Phase II Section Foreman Form Part 2 - Phase II Section Foreman.doc Form and Instruction
6 Phase II Baseline Form Attachment 11 - Phase II Baseline Form.doc Form
7 Phase II 1, 3, 6 months forms Attachment 12 - Phase II 1 3 and 6 months forms.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Phase II 1, 3, 6 months forms	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Phase I Section Foreman Form	Attachment 6 - Phase I Section Foreman Form.doc	No	No	Paper Only
Form	2	Phase I Baseline Form	Attachment 7 - Phase I Baseline Form.doc	No	No	Paper Only
Form	3	Phase I 1 month form	Attachment 8 - Phase I 1 month form.doc	No	No	Paper Only
Form and Instruction	4	Phase I Focus Group Questions Moderator Guide	Attachment 9 - Phase I Focus Group Questions.doc	No	No	Paper Only
Form and Instruction	5	Phase II Section Foreman Form	Part 2 - Phase II Section Foreman.doc	No	No	Paper Only
Form	6	Phase II Baseline Form	Attachment 11 - Phase II Baseline Form.doc	No	No	Paper Only
Form	7	Phase II 1, 3, 6 months forms	Attachment 12 - Phase II 1 3 and 6 months forms.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 6

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	324	324
Annual IC Time Burden (Hours)	135	135
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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