Pre-Evaluation Assessments of Nutrition, Physical Activity and Obesity Programs and Policies

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3 Site Visit Schedule Instructions and Template	Form and Instruction	New	Available
Form 2 Site Visit Availability Calendar	Form	New	Available
Form 4 Suggested Interviewees Form	Form and Instruction	New	Available
Form 2 Nutrition and Physical Activity Initiatives to Prevent Obesity	Form and Instruction	New	Available
Form 1 Nutrition and Physical Activity Initiatives to Prevent Obesity	Form and Instruction	New	Available
SS-Part B 01 10 2012.doc	Supporting Statement B	Uploaded 2012-01-19	Available
Att 12_ORAL INFORMED CONSENT STATEMENT.doc	Supplementary Document	Uploaded 2012-01-20	Available
Att 11_NON-DISCLOSURE AGREEMENT.doc	Supplementary Document	Uploaded 2012-01-20	Repair queued
Att 10_ENVIRONMENTAL OBSERVATION GUIDE.doc	Supplementary Document	Uploaded 2012-01-20	Available
Att 13_EXPERT CONSULTANTS SITE SELECTION GUIDANCE DOCUMENT.doc	Supplementary Document	Uploaded 2012-01-20	Available
Att 3_DNPAO Recommended community_strategies_guide.pdf	Supplementary Document	Uploaded 2012-01-19	Available
Att 2B_Summary of Public Comments.doc	Supplementary Document	Uploaded 2012-01-19	Available
Att 1_ Authorizing Legislation.doc	Supplementary Document	Uploaded 2012-01-19	Available
Att 5D_Site Visit FAQs.doc	Supplementary Document	Uploaded 2012-01-20	Available
Att 5C_Notification Email and Letter.doc	Supplementary Document	Uploaded 2012-01-20	Repair queued
Att 4C_Nomination Solicitation Email.doc	Supplementary Document	Uploaded 2012-01-19	Available
SS-Part A 01 10 2012.doc	Supporting Statement A	Uploaded 2012-01-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
200885	Lead Administrator Site Visit Schedule and Intructions	Form and Instruction	New	Site Visit Schedule Instructions and Template
200884	Lead Administrator -- Site Visit Availability Calendar	Form	New	Site Visit Availability Calendar
200883	Private Sector Partner Interviews	Instruction	New
200882	Public Sector Partner Interviews	Instruction	New
200881	Program Staff Interview	Instruction	New
200880	Evaluator Interview	Instruction	New
200879	Lead Administrator--Suggested Interviewees Form	Form and Instruction	New	Suggested Interviewees Form
200878	Lead Administrator Interview Guide	Instruction	New
200877	Nomination	Form and Instruction	New	Nutrition and Physical Activity Initiatives to Prevent Obesity
200877	Nomination	Form and Instruction	New	Nutrition and Physical Activity Initiatives to Prevent Obesity

ICR Details

OMB Control No: 0920-0927	ICR Reference No: 201201-0920-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Pre-Evaluation Assessments of Nutrition, Physical Activity and Obesity Programs and Policies
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: Approved without change	Conclusion Date: 03/30/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/23/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	24 Months From Approved
Responses	231	0	0
Time Burden (Hours)	291	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC will collect information to identify promising community-based strategies to prevent obesity by improving nutrition and physical activity. Program strategies selected for assessment must be based on CDC guidance.

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Authorizing Statute(s): US Code: 42 USC 301 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
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 54472	09/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 2730	01/19/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Evaluator Interview
Lead Administrator -- Site Visit Availability Calendar	2	Site Visit Availability Calendar
Lead Administrator Interview Guide
Lead Administrator Site Visit Schedule and Intructions	3	Site Visit Schedule Instructions and Template
Lead Administrator--Suggested Interviewees Form	4	Suggested Interviewees Form
Nomination	1, 2	Nutrition and Physical Activity Initiatives to Prevent Obesity ,   Nutrition and Physical Activity Initiatives to Prevent Obesity
Private Sector Partner Interviews
Program Staff Interview
Public Sector Partner Interviews

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ICR Summary of Burden

table that charts list 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	231	0	0	231	0	0
Annual Time Burden (Hours)	291	0	0	291	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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, one-time information collection. The number of program initiatives selected for pre-evaluation assessment may increase if additional funding becomes available.

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Annual Cost to Federal Government: $410,949

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? Yes

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: 01/23/2012

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