Information Collection

Goals and Values in Physical Activity Sub-Study #7

IC 212182 under ICR 201111-0925-003 · OMB 0925-0645.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0645 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Goals and Values in Physical Activity Sub-Study #7	Form and Instruction
1 Screener #7_attachB_screener_REV.DOC	Form and Instruction
2 Survey #7_attachE_survey.docx	Form and Instruction
3 Focus Group Protocol #7_attachF_focus group protocol.docx	Form and Instruction
JustifMemo_0925-0645_Physical Activity 7 2 14.docx Gen IC Justification Memo	IC Document
#7_attachA_advertisement_REV.DOC Attachment A- Advertisement	IC Document
#7_attachC_phone reminder_REV.DOCX Attachment C- Phone Reminder	IC Document
#7_attachD_consent_REV.DOC Attachment D- Revised Consent Form	IC Document
#7_attachG_selectedreadings.doc Attachment G- Selected Readings	IC Document
#7_attachH_OHSRP exemption.pdf Attachment H - IRB Letter	IC Document

IC Title:

Goals and Values in Physical Activity Sub-Study #7

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Survey	#7_attachE_survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Focus Group Protocol	#7_attachF_focus group protocol.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Screener	#7_attachB_screener_REV.DOC	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 296

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	296	296
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Gen IC Justification Memo	JustifMemo_0925-0645_Physical Activity 7 2 14.docx	07/03/2014
Attachment A- Advertisement	#7_attachA_advertisement_REV.DOC	07/03/2014
Attachment C- Phone Reminder	#7_attachC_phone reminder_REV.DOCX	07/03/2014
Attachment D- Revised Consent Form	#7_attachD_consent_REV.DOC	07/03/2014
Attachment G- Selected Readings	#7_attachG_selectedreadings.doc	07/03/2014
Attachment H - IRB Letter	#7_attachH_OHSRP exemption.pdf	07/03/2014

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