Information Collection

Field Test of the National Household Food Acquisition and Purchase Survey

IC 194127 under ICR 201008-0536-001 · OMB 0536-0067.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appx G.pdf	Other-null
Appx N.pdf	Other-null
Appx O.pdf	Other-null
Appx G Spanish.pdf	Other-null
Appx N Spanish.pdf	Other-null
Appx O Spanish.pdf	Other-null
Appx D.pdf	Other-null
Appx D Spanish.pdf	Other-null
Appx D revised 12-22.PDF	Other-null
Other Revised Instruments 12-22.pdf	Other-null
Appx H.pdf Meal Matrix and Calendar Magnet	IC Document
Appx H Spanish.pdf Meal Matrix and Calendar Magnet Spanish Version	IC Document
Appx I.pdf Single Book for Reporting Food Acquisitions	IC Document
Appx I Spanish.pdf Single Book for Reporting Food Acquisitions Spanish Version	IC Document
Appx J.pdf Scanner Instructions and Barcode Book	IC Document
Appx J Spanish.pdf Scanner Instructions and Barcode Book Spanish Version	IC Document
Appx K.pdf Adult Food Booklet	IC Document
Appx K Spanish.pdf Adult Food Booklet Spoanish Version	IC Document
Appx L.pdf Youth Food Booklet	IC Document
Appx L Spanish.pdf Youth Food Booklet Spanish Version	IC Document
Appx Q.pdf Image of Handheld Scanner	IC Document
Appx R.pdf CIPSEA Pledge, Long Version	IC Document
Appx T.pdf Sample Table Shells	IC Document
Appx C.pdf Advance Letter and Study Brochure	IC Document
Appx C Spanish.pdf Advance Letter and Study Brochure Spanish Version	IC Document
Appx F.pdf Consent Form	IC Document
Appx F Spanish.pdf Consent Form Spanish Version	IC Document
Appx C revised 12-22.PDF Revised Advance Letter and Study Brochure	IC Document
Appx F revised 12-22 F.PDF Revised Consent Form	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-null	Appx G.pdf	No	Paper Only
Other-null	Appx N.pdf	No	Paper Only
Other-null	Appx O.pdf	No	Paper Only
Other-null	Appx G Spanish.pdf	No	Paper Only
Other-null	Appx N Spanish.pdf	No	Paper Only
Other-null	Appx O Spanish.pdf	No	Paper Only
Other-null	Appx D.pdf	No	Paper Only
Other-null	Appx D Spanish.pdf	No	Paper Only
Other-null	Appx D revised 12-22.PDF	No	Paper Only
Other-null	Other Revised Instruments 12-22.pdf	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,414

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,878	11,878
Annual IC Time Burden (Hours)	2,494	2,494
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Meal Matrix and Calendar Magnet	Appx H.pdf	10/19/2010
Meal Matrix and Calendar Magnet Spanish Version	Appx H Spanish.pdf	10/19/2010
Single Book for Reporting Food Acquisitions	Appx I.pdf	10/19/2010
Single Book for Reporting Food Acquisitions Spanish Version	Appx I Spanish.pdf	10/19/2010
Scanner Instructions and Barcode Book	Appx J.pdf	10/19/2010
Scanner Instructions and Barcode Book Spanish Version	Appx J Spanish.pdf	10/19/2010
Adult Food Booklet	Appx K.pdf	10/19/2010
Adult Food Booklet Spoanish Version	Appx K Spanish.pdf	10/19/2010
Youth Food Booklet	Appx L.pdf	10/19/2010
Youth Food Booklet Spanish Version	Appx L Spanish.pdf	10/19/2010
Image of Handheld Scanner	Appx Q.pdf	10/19/2010
CIPSEA Pledge, Long Version	Appx R.pdf	10/19/2010
Sample Table Shells	Appx T.pdf	10/19/2010
Advance Letter and Study Brochure	Appx C.pdf	10/19/2010
Advance Letter and Study Brochure Spanish Version	Appx C Spanish.pdf	10/19/2010
Consent Form	Appx F.pdf	10/19/2010
Consent Form Spanish Version	Appx F Spanish.pdf	10/19/2010
Revised Advance Letter and Study Brochure	Appx C revised 12-22.PDF	12/22/2010
Revised Consent Form	Appx F revised 12-22 F.PDF	12/22/2010

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