The Green Housing Study

Forms and Documents

Document Name	Status
Time / Activity Form - for Mothers / Primary Caregivers Form	Modified
Illness Checklist Form	Modified
Time / Activity Form - for Children Form	Modified
Six and Twelve Month Follow-up Questionnaire - for Children Form	Modified
Six and Twelve Month Follow-up Questionnaire - for Environment Form	Modified
Three and Nine Month Phone Contact Form	Modified
Baseline Questionnaire for Children Form	Modified
Baseline Questionnaire - Demographics Form	Modified
Baseline Questionnaire Part 2 - Home Characteristics Form	Modified
Baseline Questionnaire - Home Characteristics Form	Modified
Screening Questionnaire Form	Modified
Recruitment Flyer (Cincinnati) - ENGLISH.doc Supplementary Document	2011-12-14
Recruitment Flyer (Boston) -SPANISH.doc Supplementary Document	2011-12-14
Recruitment flyer (Boston) - ENGLISH.doc Supplementary Document	2011-12-14
Recruitment Flyer (Boston) - CHINESE.doc Supplementary Document	2011-12-14
Consent Form - Clean final version (with edits from Harvard's IRB) SPANISH version Dec 4 2011.doc Supplementary Document	2011-12-14
Consent Form (Boston) Chinese version - November 30, 2011.doc Supplementary Document	2011-12-14
Assent Form - SPANISH - November 30, 2011.doc Supplementary Document	2011-12-14
Assent Form (Boston) Chinese version - November 30, 2011.doc Supplementary Document	2011-12-14
Request for Nonsubstantive change - The Green Housing study ICR# 0920--0906 (Translations).pdf Justification for No Material/Nonsubstantive Change	2011-12-14
Time Activity (Mother- Primary Caregiver) SPANISH - November 30, 2011.doc Supplementary Document	2011-12-14
Time Activity(Mother- Primary Caregiver) Chinese version - November 30, 2011.doc Supplementary Document	2011-12-14
Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D9 - Illness Checklist (Children 7-12 years) 5-10-11_CHN7.30.2011.doc Supplementary Document	2011-12-14
Appendix D10 - Time Activity (Children 7-12 yrs) 5-5-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D10 - Time Activity (Children 7-12 yrs) 5-5-11_CHN7.14.2011.doc Supplementary Document	2011-12-14
Appendix D8 -6 and 12-mo (Children 7-12 years) 5-10-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D8 -6 and 12-mo (Children 7-12 years) 5-10-11_CHN7.31.2011.doc Supplementary Document	2011-12-14
6 & 12-mo Follow-up (Environment) SPANISH - November 30, 2011.doc Supplementary Document	2011-12-14
6 & 12-mo Follow-up (Environment) Chinese version - November 30, 2011.doc Supplementary Document	2011-12-14
Appendix D5 -3 and 9-m (Children with asthma 7-12 years) 5-10-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D5 -3 and 9-m (Childrenwith asthma 7-12 years) 5-10-11_CHN7.31.2011.doc Supplementary Document	2011-12-14
Appendix D6 - Text Messages (Children with Asthma 7-12) 5-5-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D6 - Text Messages(Children with Asthma 7-12) 5-5-11_CHN7.30.2011.doc Supplementary Document	2011-12-14
Appendix D4 - Baseline (for Children 7-12 years) 5-10-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D4 - Baseline (for Children 7-12 years) 5-10-11_CHN7.13.2011.doc Supplementary Document	2011-12-14
Appendix D3 - Baseline ( Demographics) 5-12-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D3 - Baseline ( Demographics) 5-12-11_CHN8.18.2011.doc Supplementary Document	2011-12-14
Baseline (Part 2 Home Characteristics) SPANISH - November 30, 2011.doc Supplementary Document	2011-12-14
Baseline (Part 2 Home Characteristics) Chinese version - November 30, 2011.doc Supplementary Document	2011-12-14
Baseline (Home Characteristics) SPANISH - November 30, 2011.doc Supplementary Document	2011-12-14
Baseline (Home Characteristics) Chinese version - November 30, 2011.doc Supplementary Document	2011-12-14
Appendix D12 - Screening questionnaire 5-11-11 SPANISH.docx Supplementary Document	2011-12-14
Appendix D12 - Screening questionnaire 5-11-11_CHN7.9.2011.doc Supplementary Document	2011-12-14

IC Document Collections

IC ID	Document Title	Status
198577	Time / Activity Form - for Mothers / Primary Caregivers Form	Modified
198576	Illness Checklist Form	Modified
198575	Time / Activity Form - for Children Form	Modified
198574	Six and Twelve Month Follow-up Questionnaire - for Children Form	Modified
198573	Six and Twelve Month Follow-up Questionnaire - for Environment Form	Modified
198572	Three and Nine Month Phone Contact Form	Modified
198571	Monthly Text Messages Other-Text Messages	Modified
198570	Baseline Questionnaire for Children Form	Modified
198569	Baseline Questionnaire - Demographics Form	Modified
198568	Baseline Questionnaire Part 2 - Home Characteristics Form	Modified
198567	Baseline Questionnaire - Home Characteristics Form	Modified
198566	Screening Questionnaire Form	Modified

ICR Details

OMB Control No: 0920-0906	ICR Reference No: 201112-0920-013
Status: Historical Active	Previous ICR Reference No: 201107-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: The Green Housing Study
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/20/2011
	Date Received in OIRA: 12/20/2011
Terms of Clearance: Terms of clearance continue: Approval is given contengent on the understanding that CDC will submit a non-substantive change request to OMB via ROCIS before fielding translated instruments or any site-specific variations on the protocol, consent forms, or recuitment materials developed locally. Similarly, all changes to the questionnaires must be submitted to OMB.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	11/30/2014	11/30/2014
Responses	25,960	0	25,960
Time Burden (Hours)	2,356	0	2,356
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request to add Spanish and Chinese translations of the questionnaires and documents.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

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

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 12

IC Title	Form No.	Form Name
Screening Questionnaire	none	Screening Questionnaire
Baseline Questionnaire - Home Characteristics	N/A	REVISED_APPENDIX_D1_Baseline (Home Characteristics)_October 20.2011
Baseline Questionnaire Part 2 - Home Characteristics	N/A	REVISED_APPENDIX_D2_Baseline (Part 2 Home Characteristics)_October 20.11
Baseline Questionnaire for Children	none	Baseline Questionnaire Children
Monthly Text Messages
Three and Nine Month Phone Contact	none	3 and 9 Month Follow-up
Six and Twelve Month Follow-up Questionnaire - for Environment	none	6 and 12 month Follow-up - Environment
Six and Twelve Month Follow-up Questionnaire - for Children	none	6 and 12 month Follow-up Children
Time / Activity Form - for Children	none	Time / Activity - Children
Baseline Questionnaire - Demographics	none	Baseline Questionnaire (Demographics)
Illness Checklist	none	Illness Checklist
Time / Activity Form - for Mothers / Primary Caregivers	none, N/A	Time / Activity - Caregiver ,   REVISED_APPENDIX_D11_Time Activity (Mother- Primary Caregiver)_October 20.2011

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	25,960	25,960	0	0	0	0
Annual Time Burden (Hours)	2,356	2,356	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $648,000

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: 12/20/2011

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