Information Collection

State, Local and/or Tribal Agencies

IC 183226 under ICR 201103-0584-005 · OMB 0584-0548.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0548 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appx B PeerCounsBackQust Draft02-jn.doc	Other-PeerCounsBackQuest
Appx C1 DemPerProgForm.doc	Other- DemPerProgForm
Appx C2 Study Enrollment Form Draft02-jn.doc	Other-Study Enrollment Form
Appx C3 DECLINE form-jn.doc	Other-Decline Form
Appx C4 DECLINE form Spanish__postGG-jn.docx	Other-Decline Form Spanish
Appx C5 STUDY INVITATION TRACKING FORM.doc	Other-STUDY INVITATION TRACKING FORM
Appx C6 RefusalWithdraw.doc	Other- Refusal Withdraw
Appx D Contact Log Abstraction Form-jn.doc	Other-Contact Log Abstraction Form
Appx E1 LWA Staff Interview Guide 1-jn.docx	Other-LWA Staff Interview Guide
Appx E2 WICPeerC_InterviewGuide2_OMB_Draft02-jn.doc	Other-Interview Guide 2
Appx E3 WICPeerC_InterviewGuide3_OMB_Draft02-jn.doc	Other-nterview Guide 3
0584-0548 State Agency Survey paper 6-09 formatted.pdf mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey	Other-SA Survey Screenshot
Appx F1 Phase II Prelim Letter to States_5 3 11-jn.doc Phase II Prelim Letter to States	IC Document
Appx F2 FundingOppAnnounce_COMPLETE.doc Funding Opp Announce	IC Document
Appx F3 MOU_Sample-jn.docx MOU_Sample	IC Document
Appx F4 Nondisclosure.doc Nondisclosure and Confidentiality Form	IC Document

IC Title:

State, Local and/or Tribal Agencies

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-PeerCounsBackQuest		No		Paper Only
Other- DemPerProgForm		No		Paper Only
Other-Study Enrollment Form		No		Paper Only
Other-Decline Form		No		Paper Only
Other-Decline Form Spanish		No		Paper Only
Other-STUDY INVITATION TRACKING FORM		No		Paper Only
Other- Refusal Withdraw		No		Paper Only
Other-Contact Log Abstraction Form	www.notcreated.com	Yes	Yes	Fillable Fileable Signable
Other-LWA Staff Interview Guide		No		Paper Only
Other-Interview Guide 2		No		Paper Only
Other-nterview Guide 3		No		Paper Only
Other-SA Survey Screenshot	http://mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: FNS Studies and Reports - FNS 8

FR Citation: 56 FR 19079

Number of Respondents: 96

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 43 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,304	4,734	570
Annual IC Time Burden (Hours)	1,108	651	457
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Phase II Prelim Letter to States		07/20/2011
Funding Opp Announce		07/20/2011
MOU_Sample		07/20/2011
Nondisclosure and Confidentiality Form		07/20/2011

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].