The Healthy Communities Study: How Communities Shape Childrens Health (NHLBI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Physicians/Medical Secretaries	Form and Instruction	Modified	Available
Form 1 State Health Department Employees	Form and Instruction	Modified	Available
Form 1 Physical Education Instructiors	Form and Instruction	Modified	Available
Form 1 Food Service Personnel	Form and Instruction	Modified	Available
Form 1 Key Informants	Form and Instruction	Modified	Available
Form 1 Key Informats (screening)	Form and Instruction	Modified	Available
Form 1 Children	Form and Instruction	Modified	Available
Form 1 Parents/Caregivers (who refused)	Form and Instruction	Modified	Available
Form 1 Second Parents	Form and Instruction	Modified	Available
Form 1 Parents/Caregivers	Form and Instruction	Modified	Available
Form 1 Parents (screening)	Form and Instruction	Modified	Available
REVISED_HCS_OMB_SSB__Dec 2011.docx	Supporting Statement B	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 23_PRIVACY ACT MEMO_SEPTEMBER 2011 FINAL for OMB.pdf	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 22_IRB APPROVAL_SEPTEMBER 2011 FINAL for OMB.pdf	Supplementary Document	Uploaded 2012-01-17	Available
Copy of HCS_SSB_ATTACH 1_NOMINATION FORM_SEPTEMBER 2011 FINAL for OMB.xlsx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSB_ATTACH 2_STATISTICAL POWER_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 27_KI BURDEN BY PROTOCOL TYPE_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 26_PARENT-CHILD BY PROTOCOL TYPE_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 21_SUBCOMMITTEES_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
REVISED_HCS_OMB_SSA_ATTACH 15_OBSERVATIONS PROTOCOLS_DEC 2011.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 25_PARENT-CHILD BY PROTOCOL COMPONENT_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 20_NCCOR LETTER_SEPTEMBER 2011 FINAL for OMB-1.pdf	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 12_KI BROCHURE_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 11_KI LETTER_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 24_CALC OF PARENT-CHILD BURDEN_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
REVISED_HCS_OMB_SSA_ATTACH 5_FAMILY BROCHURE_Dec 2011.docx	Supplementary Document	Uploaded 2012-01-17	Available
REVISED_HCS_SSA_ATTACH 4_FAMILY LETTER_DEC 2011.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 3_NHLBI COUNCIL ROSTER_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 2_BEE ROSTER_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
HCS_SSA_ATTACH 1_GLOSSARY_SEPTEMBER 2011 FINAL for OMB.docx	Supplementary Document	Uploaded 2012-01-17	Available
REVISED_HCS_OMB_SSA _Dec 2011.docx	Supporting Statement A	Uploaded 2012-01-17	Available

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 0925-0649	ICR Reference No: 201201-0925-002
Status: Historical Active	Previous ICR Reference No: 201109-0925-006
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: The Healthy Communities Study: How Communities Shape Childrens 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: Approved with change	Conclusion Date: 01/30/2012
	Date Received in OIRA: 01/20/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved
Responses	90,880	0	0
Time Burden (Hours)	33,145	0	0
Cost Burden (Dollars)	0	0	0

---

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.

---

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

Citations for New Statutory Requirements: None

---

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

---

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

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Parents/Caregivers (who refused)	1	Parents/Caregivers (who refused)
Children	1	Child Protocol
Key Informats (screening)	1	KI Screening
Key Informants	1	KI Protocol
Food Service Personnel	1	Lunch Personnel Protocol
Physicians/Medical Secretaries	1	record Retrieval Protocol
Parents (screening)	1	Family Screening
Parents/Caregivers	1	parent Protocol
Second Parents	1	Second Parents
Physical Education Instructiors	1	PE Instructor Protocol
State Health Department Employees	1	Health Department Script

---

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	90,880	0	0	90,880	0	0
Annual Time Burden (Hours)	33,145	0	0	33,145	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 ICR.

---

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

---

Common Form ICR:  No

---

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: 01/20/2012

---