Information Collection

State Recruitment and Data Collection

IC 197637 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⚠️ Notice: This information collection may be referencing outdated material.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:

2013-07-09 - Reinstatement with change of a previously approved collection

Documents and Forms

Document Name Document Type
Form 15 State Recruitment and Data Collection Form and Instruction
9 Health Education State Questionnaire Appendix G-1 Health Education_State.doc Form and Instruction
10 Physical Education and Activity State Questionnaire Appendix G-2 Physical Education_State.doc Form and Instruction
11 Health Services State Questionnaire Appendix G-3 Health Services_State.doc Form and Instruction
12 Nutrition Services State Questionnaire Appendix G-4 Nutrition Services_State.doc Form and Instruction
13 Healthy and Safe School Environment State Questionnaire Appendix G-5 Healthy&Safe Environment_State.doc Form and Instruction
14 Mental Health and Social Services State Questionnaire Appendix G-6 MHSS_State.doc Form and Instruction
15 Telephone Script For Recruitment and Respondent Identifi Appendix H-3 State Recruitment Script.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
Appendix H-1 State Letter of Invitation.doc Appendix H-1 State Letter of Invitation IC Document
Appendix H-5 State-level Content Outlines.doc Appendix H-5 State-level Content Outlines IC Document
Appendix E-1 State Participant Notification Document-revised.docx Appendix E-1 State Participant Notification Document-revised IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Recruitment and 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	15	Telephone Script For Recruitment and Respondent Identification: State	Appendix H-3 State Recruitment Script.doc	Yes	Yes	Fillable Fileable
Form and Instruction	9	Health Education State Questionnaire	Appendix G-1 Health Education_State.doc	Yes	Yes	Fillable Fileable
Form and Instruction	10	Physical Education and Activity State Questionnaire	Appendix G-2 Physical Education_State.doc	Yes	Yes	Fillable Fileable
Form and Instruction	11	Health Services State Questionnaire	Appendix G-3 Health Services_State.doc	Yes	Yes	Fillable Fileable
Form and Instruction	12	Nutrition Services State Questionnaire	Appendix G-4 Nutrition Services_State.doc	Yes	Yes	Fillable Fileable
Form and Instruction	13	Healthy and Safe School Environment State Questionnaire	Appendix G-5 Healthy&Safe Environment_State.doc	Yes	Yes	Fillable Fileable
Form and Instruction	14	Mental Health and Social Services State Questionnaire	Appendix G-6 MHSS_State.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Education

Subfunction: Elementary, Secondary, and Vocational Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	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	51	51
Annual IC Time Burden (Hours)	204	204
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
Appendix H-1 State Letter of Invitation	Appendix H-1 State Letter of Invitation.doc	05/02/2011
Appendix H-5 State-level Content Outlines	Appendix H-5 State-level Content Outlines.doc	05/02/2011
Appendix E-1 State Participant Notification Document-revised	Appendix E-1 State Participant Notification Document-revised.docx	05/02/2011

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