National Healthy Worksite Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Att I-2_IRB_RTI.pdf	Supplementary Document	Uploaded 2012-07-09	Available
SS_Part B_052412.docx	Supporting Statement B	Uploaded 2012-06-04	Available
Att I-1_IRB VHM[1].zip	Supplementary Document	Uploaded 2012-06-06	Repair queued
Att H-2 HeadCoachDiscGude.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att H-1_ComutyDirDiscGude.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att C-5_NHWP RiskStratLogic.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att C-4_DataFlowDiagram_ProgramProvider.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att C-2_ProjProf_of_NHWP_Empr-Emple_Part.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att B-3_FRN Prog_Annc.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att C-1_Prog ObjSurvInst CrossWalk.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att C-3_Employer_EmployeesDataFlowDiagram.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att B-2_FRN 60dy Summary of Pub Comts.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att B-1_FRN_60dy.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att A-2_Autho Leg_PHSA.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att A-1_-Autho Leg.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att A-3_Autho Leg_ACA_PL_111-148_Section_4002 PPHF.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att G-5 NHWP FAQs.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att G-4 Understand HlthScrRes.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att G-3 PhysRefForm (1).pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att G-2 HIPAA Privacy Practices.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att D-3_NHWP_ErIntervInst.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att D-1_ErEligReq.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att D-3_NHWP_ErIntervInst.pdf	Supplementary Document	Uploaded 2012-06-04	Available
Att D-1_ErEligReq.pdf	Supplementary Document	Uploaded 2012-06-04	Available
SS_Part A_052412.docx	Supporting Statement A	Uploaded 2012-06-04	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202693	Health Screening Consent / Contact Form	Other-word	New
202692	Wellness Challenge Logs (Employee) - Nutrition & Physical Activity / Lifestyle Tracker	Other-WORD	New
202691	Wellness Challenge Logs (Employee) - Step into Health	Other-WORD	New
202690	Wellness Challenge Logs (Employee) - Quench Your Thirst	Other-WORD	New
202689	Wellness Challenge Logs (Employee) - Mix It Up	Other-WORD	New
202688	Wellness Challenge Logs (Employee) - Maintain Don't Gain	Other-word	New
202687	Wellness Challenge Logs (Employee) - Lower Your Weight by Eight	Other-WORD	New
202686	Wellness Challenge Logs (Employee) - Feel Fit with Fiber	Other-Word	New
202685	Satisfaction Survey (Employee)	Other-WORD	New
202684	Success Story Consent Form	Other-WORD	New
202683	All Employee Survey	Other-WORD	New
202682	Community Participant Emgagement Feedback Survey	Other-WORD	New
202681	Worksite Health 101 Training Survey: Part IV	Other-WORD	New
202680	Worksite Health 101 Training Survey: Part I-III	Other-WORD	New
202679	Employer Follow-Up Survey	Other-WORD	New
202678	Employer Discussion Guide: Wellness Committee (Case Studies)	Other-WORD	New
202677	Employer Discussion Guide: Steering Committee Members (Case Studies)	Other-WORD	New
202676	Health Screening Site Interview Form	Other-WORD	New
202675	Employer Information Form	Other-WORD	New
202674	Employee Eligiblity File Format Requirements	Other-WORD	New
202673	Organizational Assessment (Employer)	Other-WORD	New
202672	Employer Phone Interview Guide	Other-WORD	New

ICR Details

OMB Control No: 0920-0965	ICR Reference No: 201206-0920-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Healthy Worksite Program
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: Withdrawn	Conclusion Date: 11/21/2012
	Date Received in OIRA: 06/13/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is establishing a new, comprehensive workplace health program, the National Healthy Worksite Program (NHWP). The purpose of the program is to imporve the health of workers and their families. CDC will work with employers to implement and evaluate workplace-based programs that address physical activity, nutrition, and tobacco use.

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Authorizing Statute(s): None

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:
	77 FR 8874	02/15/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 34951	06/12/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 22

table that charts list of burden

IC Title	Form No.	Form Name
Employer Phone Interview Guide
Organizational Assessment (Employer)
Employee Eligiblity File Format Requirements
Employer Information Form
Health Screening Site Interview Form
Employer Discussion Guide: Steering Committee Members (Case Studies)
Employer Discussion Guide: Wellness Committee (Case Studies)
Employer Follow-Up Survey
Worksite Health 101 Training Survey: Part I-III
Worksite Health 101 Training Survey: Part IV
Community Participant Emgagement Feedback Survey
All Employee Survey
Success Story Consent Form
Satisfaction Survey (Employee)
Wellness Challenge Logs (Employee) - Feel Fit with Fiber
Wellness Challenge Logs (Employee) - Lower Your Weight by Eight
Wellness Challenge Logs (Employee) - Maintain Don't Gain
Wellness Challenge Logs (Employee) - Mix It Up
Wellness Challenge Logs (Employee) - Quench Your Thirst
Wellness Challenge Logs (Employee) - Step into Health
Wellness Challenge Logs (Employee) - Nutrition & Physical Activity / Lifestyle Tracker
Health Screening Consent / Contact Form

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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 information collect request supporting a new programmatic initiative. Information will be collected for program evaluation.

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Annual Cost to Federal Government: $1,017,108

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]? Yes

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: 06/13/2012

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