Pilot Study of Community-Based Surveillance of Supports for Healthy Eating/Active Living (HE/AL)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CBS Survey	Form	New	Available
CBS OMB Part B 01_19_12.doc	Supporting Statement B	Uploaded 2012-01-24	Available
Appendix D3. Participant Consent Form 01_19_12.docx	Supplementary Document	Uploaded 2012-01-24	Available
Appendix D1. Study Invitation Letter 01_19_12.doc	Supplementary Document	Uploaded 2012-01-24	Available
Appendix D2. Study Fact Sheet 01_19_12.doc	Supplementary Document	Uploaded 2012-01-24	Available
Appendix F. References 01_09_12.doc	Supplementary Document	Uploaded 2012-01-24	Available
Appendix E. Example Tables 01_09_12.doc	Supplementary Document	Uploaded 2012-01-24	Available
Appendix B2. Summary of Public Comments.doc	Supplementary Document	Uploaded 2012-01-24	Available
Appendix B1. Federal Register Notice.pdf	Supplementary Document	Uploaded 2012-01-24	Available
Appendix A. Supporting Legislation.doc	Supplementary Document	Uploaded 2012-01-24	Available
Appendix D5. Instructions 01_19_12.doc	Supplementary Document	Uploaded 2012-01-24	Available
CBS OMB Part A 01_19_12.doc	Supporting Statement A	Uploaded 2012-01-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201063	Telephone Non-Response Follow-up Contact Script	Other-Telephone Script	New
201062	CBS Survey	Form	New

ICR Details

OMB Control No: 0920-0934	ICR Reference No: 201202-0920-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Pilot Study of Community-Based Surveillance of Supports for Healthy Eating/Active Living (HE/AL)
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: 05/07/2012
	Date Received in OIRA: 02/08/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2013	12 Months From Approved
Responses	1,000	0	0
Time Burden (Hours)	450	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Disease Control and Prevention requests approval to conduct a pilot study, to examine the feasibility of establishing a new national surveillance system that will monitor local government policies which support healthy eating and active living.

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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 62068	10/06/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 5519	02/03/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
CBS Survey	none, none	CBS Questionnaire ,   Survey Screenshots
Telephone Non-Response Follow-up Contact Script

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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	1,000	0	0	1,000	0	0
Annual Time Burden (Hours)	450	0	0	450	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 data collection.

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Annual Cost to Federal Government: $345,120

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: 02/08/2012

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