State, Local and/or Tribal Agencies

WIC Breastfeeding Peer Counseling Study Phase 2

OMB: 0584-0548

IC ID: 183226

Documents and Forms
Document Name
Document Type
Other-PeerCounsBackQuest
Other- DemPerProgForm
Other-Study Enrollment Form
Other-Decline Form
Other-Decline Form Spanish
Other-STUDY INVITATION TRACKING FORM
Other- Refusal Withdraw
Other-Contact Log Abstraction Form
Other-LWA Staff Interview Guide
Other-Interview Guide 2
Other-nterview Guide 3
Other-SA Survey Screenshot
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

State, Local and/or Tribal Agencies
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-PeerCounsBackQuest Appx B PeerCounsBackQust Draft02-jn.doc No   Paper Only
Other- DemPerProgForm Appx C1 DemPerProgForm.doc No   Paper Only
Other-Study Enrollment Form Appx C2 Study Enrollment Form Draft02-jn.doc No   Paper Only
Other-Decline Form Appx C3 DECLINE form-jn.doc No   Paper Only
Other-Decline Form Spanish Appx C4 DECLINE form Spanish__postGG-jn.docx No   Paper Only
Other-STUDY INVITATION TRACKING FORM Appx C5 STUDY INVITATION TRACKING FORM.doc No   Paper Only
Other- Refusal Withdraw Appx C6 RefusalWithdraw.doc No   Paper Only
Other-Contact Log Abstraction Form Appx D Contact Log Abstraction Form-jn.doc www.notcreated.com Yes Yes Fillable Fileable Signable
Other-LWA Staff Interview Guide Appx E1 LWA Staff Interview Guide 1-jn.docx No   Paper Only
Other-Interview Guide 2 Appx E2 WICPeerC_InterviewGuide2_OMB_Draft02-jn.doc No   Paper Only
Other-nterview Guide 3 Appx E3 WICPeerC_InterviewGuide3_OMB_Draft02-jn.doc No   Paper Only
Other-SA Survey Screenshot 0584-0548 State Agency Survey paper 6-09 formatted.pdf http://mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey Yes Yes Fillable Fileable Signable

Health Public Health Monitoring

FNS Studies and Reports - FNS 8  56 FR 19079

96 0
   
State, Local, and Tribal Governments
 
   43 %

  Requested 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 5,304 0 4,734 0 0 570
Annual IC Time Burden (Hours) 1,108 0 651 0 0 457
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Phase II Prelim Letter to States Appx F1 Phase II Prelim Letter to States_5 3 11-jn.doc 07/20/2011
Funding Opp Announce Appx F2 FundingOppAnnounce_COMPLETE.doc 07/20/2011
MOU_Sample Appx F3 MOU_Sample-jn.docx 07/20/2011
Nondisclosure and Confidentiality Form Appx F4 Nondisclosure.doc 07/20/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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