Information Collection

State, Local and/or Tribal Agencies

IC 183226 under ICR 201111-0584-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 C5 STUDY INVITATION TRACKING FORM.doc	Other-STUDY INVITATION TRACKING FORM
Appx D Contact Log Abstraction Form-jn.doc www.notcreated.com	Other-Contact Log Abstraction Form
Appx E1 LWA Staff Interview Guide 1-jn.docx	Other-LWA Staff Interview Guide
Appx E2 WICPeerC_InterviewGuide2_OMB_Draft03-jn.pdf	Other-Interview Guide 2
Appx E3 WICPeerC_InterviewGuide3_OMB_Draft03-jn.pdf	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 B PeerCounsBackQust FinalOMB.pdf	Other-Appx B PeerCounsBackQust Final
Appx E1 LWA Staff Interview Guide 1_FinalOMB.pdf	Other-Appx B PeerCounsBackQust Final
Appx E2 WICPeerC_InterviewGuide2_FinalOMB.pdf	Other-Appx E2 WICPeerC_InterviewGuid
Appx E3 WICPeerC_InterviewGuide3_FinalOMB.pdf	Other-Appx E3 WICPeerC_InterviewGuid
Appx F1 Phase II Prelim Letter to States_5 3 11-jn.docx 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
ResptoOMBTermsofClearance.doc ResptoOMBTermsofClearance	IC Document
OMB_reply_FNSfollowup Draft03 final.docx OMB_reply_FNSfollowup	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	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-STUDY INVITATION TRACKING FORM	Appx C5 STUDY INVITATION TRACKING FORM.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_Draft03-jn.pdf		No		Paper Only
Other-nterview Guide 3	Appx E3 WICPeerC_InterviewGuide3_OMB_Draft03-jn.pdf		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
Other-Appx B PeerCounsBackQust FinalOMB	Appx E1 LWA Staff Interview Guide 1_FinalOMB.pdf		No		Paper Only
Other-Appx E2 WICPeerC_InterviewGuide2_FinalOMB	Appx E2 WICPeerC_InterviewGuide2_FinalOMB.pdf		No		Paper Only
Other-Appx E3 WICPeerC_InterviewGuide3_FinalOMB	Appx E3 WICPeerC_InterviewGuide3_FinalOMB.pdf		No		Paper Only
Other-Appx B PeerCounsBackQust FinalOMB	Appx B PeerCounsBackQust FinalOMB.pdf		No		Paper Only

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
	Approved	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	Appx F1 Phase II Prelim Letter to States_5 3 11-jn.docx	11/21/2011
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
ResptoOMBTermsofClearance	ResptoOMBTermsofClearance.doc	11/21/2011
OMB_reply_FNSfollowup	OMB_reply_FNSfollowup Draft03 final.docx	12/01/2011

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