Information Collection

Assessing Adoption and the Living a Balanced Life With Diabetes Tookit

IC 208194 under ICR 201008-0920-003 · OMB 0920-0864.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessing Adoption and the Living a Balanced Life With Diabetes Tookit	Form and Instruction
Assessing Adoption and Use of the Living a Balanced Life Attachment 1a_Full Text of the Survey and Consent.docx	Form and Instruction
Screenshots for Living a Balanced Life with Diabetes Ass Attachment 1b_Screenshots of the Survey and Consent.docx	Form and Instruction
0920-0864_GenIC10_SS Part A_NDEP AIAN Toolkit_08 02 13.docx 0920-0864_GenIC10_SS Part A_NDEP AIAN Toolkit_08 02 13	IC Document
0920-0864_GenIC10_SS Part B_NDEP AIAN Toolkit_08 02 13.docx 0920-0864_GenIC10_SS Part B_NDEP AIAN Toolkit_08 02 13	IC Document
Attachment 2_Advance email_NDEP AIAN Toolkit.docx Attachment 2_Advance email_NDEP AIAN Toolkit	IC Document
Attachment 3_reminder email_NDEP AIAN Toolkit.docx Attachment 3_reminder email_NDEP AIAN Toolkit	IC Document
rpt684_IRB_Form.pdf rpt684_IRB_Form	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Assessing Adoption and Use of the Living a Balanced Life with Diabetes Toolkit	Attachment 1a_Full Text of the Survey and Consent.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Screenshots for Living a Balanced Life with Diabetes Assessment Survey	Attachment 1b_Screenshots of the Survey and Consent.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	300	0	0	0	0	0
Annual IC Time Burden (Hours)	100	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0920-0864_GenIC10_SS Part A_NDEP AIAN Toolkit_08 02 13	0920-0864_GenIC10_SS Part A_NDEP AIAN Toolkit_08 02 13.docx	08/09/2013
0920-0864_GenIC10_SS Part B_NDEP AIAN Toolkit_08 02 13	0920-0864_GenIC10_SS Part B_NDEP AIAN Toolkit_08 02 13.docx	08/09/2013
Attachment 2_Advance email_NDEP AIAN Toolkit	Attachment 2_Advance email_NDEP AIAN Toolkit.docx	08/09/2013
Attachment 3_reminder email_NDEP AIAN Toolkit	Attachment 3_reminder email_NDEP AIAN Toolkit.docx	08/09/2013
rpt684_IRB_Form	rpt684_IRB_Form.pdf	08/09/2013

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