Information Collection

District Data Collection

IC 197636 under ICR 201105-0920-006 · OMB 0920-0445.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0445 can be found here:

Documents and Forms

Document Name Document Type
Form 2 District Data Collection Form and Instruction
2 Health Education District Questionnaire Appendix G-7 Health Education_District.doc Form and Instruction
3 Physical Education and Activity District Questionnaire Appendix G-8 Physical Education_District.doc Form and Instruction
4 Health Services District Questionnaire Appendix G-9 Health Services_District.doc Form and Instruction
5 Nutrition Services District Questionnaire Appendix G-10 Nutrition Services_District.doc Form and Instruction
6 Healthy and Safe School Environment District Questionnai Appendix G-11 Healthy&Safe Environment.doc Form and Instruction
7 Mental Health and Social Services District Questionnaire Appendix G-12 MHSS_District.doc Form and Instruction
8 Faculty and Staff Health Promotion Appendix G-13 FSHP_District.doc Form and Instruction
Appendix H-4 District Recruitment Script.doc Appendix H-4 District Recruitment Script IC Document
Appendix E-2 District Participant Notification Document.doc Appendix E-2 District Participant Notification Document IC Document
Appendix H-6 District-level Content Outlines.doc Appendix H-6 District-level Content Outlines IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	District Data Collection	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Health Education District Questionnaire	Appendix G-7 Health Education_District.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3	Physical Education and Activity District Questionnaire	Appendix G-8 Physical Education_District.doc	Yes	Yes	Fillable Fileable
Form and Instruction	4	Health Services District Questionnaire	Appendix G-9 Health Services_District.doc	Yes	Yes	Fillable Fileable
Form and Instruction	5	Nutrition Services District Questionnaire	Appendix G-10 Nutrition Services_District.doc	Yes	Yes	Fillable Fileable
Form and Instruction	6	Healthy and Safe School Environment District Questionnaire	Appendix G-11 Healthy&Safe Environment.doc	Yes	Yes	Fillable Fileable
Form and Instruction	7	Mental Health and Social Services District Questionnaire	Appendix G-12 MHSS_District.doc	Yes	Yes	Fillable Fileable
Form and Instruction	8	Faculty and Staff Health Promotion	Appendix G-13 FSHP_District.doc	Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Elementary, Secondary, and Vocational Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 685	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	685	685
Annual IC Time Burden (Hours)	2,854	2,854
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix H-4 District Recruitment Script	Appendix H-4 District Recruitment Script.doc	04/29/2011
Appendix E-2 District Participant Notification Document	Appendix E-2 District Participant Notification Document.doc	04/29/2011
Appendix H-6 District-level Content Outlines	Appendix H-6 District-level Content Outlines.doc	04/29/2011

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