The Healthy Communities Study: How Communities Shape Children?s Health (NHLBI)

Forms and Documents

Document Name	Status
Form 19 Physicians/Medical Secretaries Form and Instruction	New
Form 18 State Health Department Employees Form and Instruction	New
Form 17 Physical Education Instructors Form and Instruction	New
Form 16 Food Service Personnel Form and Instruction	New
Form 14 Key Informants Form and Instruction	New
Form 13 Key Informants (screening) Form and Instruction	New
Form 10 Children Form and Instruction	New
Form 9 Parents/Caregivers (who refused) Form and Instruction	New
Form 8 Second Parents Form and Instruction	New
Form 7 Parents/Caregivers Form and Instruction	New
Form 6 Parents (screening) Form and Instruction	New
FINAL-HCS-OMB-Supporting Statement_B_ SEPTEMBER2011.docx Supporting Statement B	2011-09-14
HCS_SSB_ATTACH 2_STATISTICAL POWER_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
Copy of HCS_SSB_ATTACH 1_NOMINATION FORM_SEPTEMBER 2011 FINAL for OMB.xlsx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 27_KI BURDEN BY PROTOCOL TYPE_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 26_PARENT-CHILD BY PROTOCOL TYPE_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 25_PARENT-CHILD BY PROTOCOL COMPONENT_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 24_CALC OF PARENT-CHILD BURDEN_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 23_PRIVACY ACT MEMO_SEPTEMBER 2011 FINAL for OMB.pdf Supplementary Document	2011-09-14
HCS_SSA_ATTACH 22_IRB APPROVAL_SEPTEMBER 2011 FINAL for OMB.pdf Supplementary Document	2011-09-14
HCS_SSA_ATTACH 21_SUBCOMMITTEES_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 20_NCCOR LETTER_SEPTEMBER 2011 FINAL for OMB-1.pdf Supplementary Document	2011-09-14
HCS_SSA_ATTACH 15_OBSERVATIONS PROTOCOLS_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 12_KI BROCHURE_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 11_KI LETTER_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 5_FAMILY BROCHURE_SEPTEMBER2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 4_FAMILY LETTER_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 3_NHLBI COUNCIL ROSTER_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 1_GLOSSARY_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
HCS_SSA_ATTACH 2_BEE ROSTER_SEPTEMBER 2011 FINAL for OMB.docx Supplementary Document	2011-09-14
FINAL_HCS_OMB_Supporting_Statement_A _September 2011[1].docx Supporting Statement A	2011-09-28

IC Document Collections

IC ID	Document Title	Status
199554	Physicians/Medical Secretaries Form and Instruction	New
199553	State Health Department Employees Form and Instruction	New
199552	Physical Education Instructors Form and Instruction	New
199551	Food Service Personnel Form and Instruction	New
199550	Key Informants Form and Instruction	New
199549	Key Informants (screening) Form and Instruction	New
199548	Children Form and Instruction	New
199547	Parents/Caregivers (who refused) Form and Instruction	New
199546	Second Parents Form and Instruction	New
199545	Parents/Caregivers Form and Instruction	New
199544	Parents (screening) Form and Instruction	New

ICR Details

OMB Control No: 0925-0649	ICR Reference No: 201109-0925-006
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: The Healthy Communities Study: How Communities Shape Children?s Health (NHLBI)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 12/27/2011
	Date Received in OIRA: 09/29/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The HCS is an observational study of communities conducted over five years that aims to (1) determine the associations between community programs/policies and body mass index (BMI), diet, and physical activity in children; and (2) identify the community, family, child factors that modify or mediate the associations between community programs/policies and BMI, diet, and physical activity in children. A total of 279 communities and over 23,000 children and their parents will be part of the HCS. A HCS community is defined as a high school catchment area and the age range of children is 3-15 years upon entry into the study. Data will be collected on at least 78 children within each community (three boys and three girls for each yearly age interval). The study will examine quantitative and qualitative information obtained from community-based initiatives, community characteristics (e.g., school environment), and from child and parent assessments and measurements of physical activity levels and dietary practices of children, and children's and parent's BMI.

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Authorizing Statute(s): US Code: 42 USC 285b Name of Law: NHLBI Mandate
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 35452	06/17/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 59706	09/27/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 11

IC Title	Form No.	Form Name
Parents/Caregivers (who refused)	9	Parent Refusal Protocol
Children	10	Child Protocol
Key Informants (screening)	13	KI Screening
Key Informants	14	KI Protocol
Food Service Personnel	16	Lunch Personnel Protocol
Physical Education Instructors	17	PE Instructor Protocol
State Health Department Employees	18	Health Dept. Script
Physicians/Medical Secretaries	19	Record Retrieval Protocol
Parents (screening)	6	Family Screener
Parents/Caregivers	7	Parent Protocol
Second Parents	8	2nd Parent Protocol

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $109,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/29/2011

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