Information Collection

Phase II - 1,3,6 Months Form

IC 191374 under ICR 201001-0920-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Form Form and Instruction
1 Phase 1 Section Foreman Form Attachment 6 - Phase I Section Foreman Form.doc Form and Instruction
2 Phase 1 Baseline Form Attachment 7 - Phase I Baseline Form.doc Form
3 Phase 1 - 1 Month Form Attachment 8 - Phase I 1 month form.doc Form
4 Phase 1 - Focus Group Questions Attachment 9 - Phase I Focus Group Questions.doc Form and Instruction
5 Phase II - Section Foreman Form Attachment 10 - Phase II Section Foreman Form.doc Form
6 Phase II Baseline Form Attachment 11 - Phase II Baseline Form.doc Form
7 Phase II - 1, 3, 6 Months Form Attachment 12 - Phase II 1 3 and 6 months forms.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Phase II - 1,3,6 Months Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 1 Section Foreman Form	Attachment 6 - Phase I Section Foreman Form.doc	No	No	Paper Only
Form	2	Phase 1 Baseline Form	Attachment 7 - Phase I Baseline Form.doc	No	No	Paper Only
Form	3	Phase 1 - 1 Month Form	Attachment 8 - Phase I 1 month form.doc	No	No	Paper Only
Form and Instruction	4	Phase 1 - Focus Group Questions	Attachment 9 - Phase I Focus Group Questions.doc	No	No	Paper Only
Form	5	Phase II - Section Foreman Form	Attachment 10 - Phase II Section Foreman Form.doc	No	No	Paper Only
Form	6	Phase II Baseline Form	Attachment 11 - Phase II Baseline Form.doc	No	No	Paper Only
Form and Instruction	7	Phase II - 1, 3, 6 Months Form	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 %

	Approved	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.