Information Collection

Deliberative Poll on Obesity Prevention and Control

IC 194804 under ICR 201010-0920-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Deliberative Poll on Obesity Prevention and Control	Form
Questionnaire Attach 4.1_Questionnaire-Poll Obesity Prevention.doc	Form
Attach 4a_Consent Form for Questionnaire Only Respondents.doc 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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	None	Questionnaire	Attach 4.1_Questionnaire-Poll Obesity Prevention.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 950

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,900	1,900
Annual IC Time Burden (Hours)	950	950
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent form	Attach 4a_Consent Form for Questionnaire Only Respondents.doc	09/16/2010

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