Generic Clearance to Conduct Formative Research

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	Available
Form FNS 817 Level III Feedback Form	Form	Unchanged	Available
Form FNS 816 Level I Feedback	Form	Unchanged	Available
Form FNS 780 Bronze/Silver Award Application	Form and Instruction	Unchanged	Available
Form FNS 779 Gold/Gold Award of Distinction Application	Form and Instruction	Unchanged	Available
Form FNS 812 Activity Kit User Response Form	Form	Unchanged	Available
Form FNS 811 User Response Card	Form	Unchanged	Available
Form FNS 810 Promote Fruits and Vegetables in Your Workplace	Form	Unchanged	Available
Form FNS 809 Promote and Support Breastfeeding Feedback	Form	Unchanged	Available
Form FNS 808 Event Feedback (Power Panther)	Form	Unchanged	Available
Form FNS 807 Power Panther Request and Agreement	Form	Unchanged	Available
Form FNS 813 Power Partner Commitment	Form	Unchanged	Repair queued
Form FNS 805 Kids User Response	Form	Unchanged	Available
Form FNS 804 Healthy Lifestyle User Response	Form	Unchanged	Available
Form FNS 803 User Response Form	Form	Unchanged	Available
Form FNS 792 Golden Grocer Award Nomination Form	Form and Instruction	Unchanged	Available
Form FNS-793 FNS Core Nutrition Messags Feedback Form	Form and Instruction	Unchanged	Available
Form FNS-791 Promising Practices Submission Form	Form and Instruction	Unchanged	Available
Form FNS-790 Hunger Champions Nomination Form	Form and Instruction	Unchanged	Available
Form FNS-780 Bronze/Silver Recognizing Excellence in Nutrition and Physical Activity	Form and Instruction	Unchanged	Available
Form FNS-779 Gold Application for Recognizing Excellence in Nutrition and Physical Activity	Form and Instruction	Unchanged	Available
Form FNS-781 Team Nutrition School Enrollment Form	Form and Instruction	Unchanged	Available
justification memo to increase burden hours overall.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-07-25	Available
change justification memo 8-2-2010.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2010-08-04	Available
HUSSC change justification memo 7-8-2010.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2010-07-12	Available
Dietary Guidelines Jan 05.pdf	Supplementary Document	Uploaded 2006-12-27	Available
Supporting Statement 3-30-2010.doc	Supporting Statement A	Uploaded 2010-03-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206348	Request Approval to Perform Research for Team Nutrition Posters for Elementary and Middle School	Other-A_FNS Screener_Student Focus Groupsincentive.doc	New
205950	Request Approval to Perform Research for Team Nutrition Posters for Elementary and Middle School	Other-B_FNS Screener_Food Service Directorincentive.doc	New
205284	Testing the Modified FNS Core Nutrition Messages for Spanish-Speaking Audiences	Other-Attachment A - Focus Group Screening Questionnaire	New
203735	Parent/Student REV 2	Other-B - Parent Letter_Survey_Consent Form_FINAL	New
203722	State Agencies (Prinicpal & Teachers) REV 2	Other-A - Teacher Letter_Survey_Consent Form_FINAL	New
202851	HUSSC 2012	Other-FNS-780 2012 HUSSC Bronze-Silver Application	Unchanged
202026	MyPlate Parent/Student REV	Other-Attachment B - Parent Letter_Response Form_Consent Form fo	Unchanged
201535	MyPlate	Other-Attachment A - Teacher Letter_Response Form_Consent Form	Unchanged
200916	Zero Income (I/H)	Other-Attachment A1 - Interview Guide - English	Unchanged
200681	Team Nutrtition Curriculum Messages for 5 & 6th Grades (I/H)	Other-Attachment C	Unchanged
200504	Team Nutrition Curriculum Messages for 5 & 6th Grades (SA)	Other-Teacher Letter Teacher Respnse Teacher Consent	Unchanged
200310	Zero Income (SA)	Other-Recruitment Letter to states	Unchanged
198917	Team Nutrition Curriculum (State Agencies: Teachers & Foodservice Staff)	Other-Protocol for Administration of Student Pretest	Unchanged
198840	Team Nutrition Curriculum (I/H)	Other-Student Pretest	Unchanged
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
198156	What You Can Do for School Wellness Communication Tools Testing	Form and Instruction	Unchanged	NA
195938	Team Nutrition Gardens Formative Research	Other-Focus Group Moderator Guide	Unchanged
195334	Healthy School Environment	Other-Screening Questionnaire	Unchanged
194845	Core Nutrition Messages - Revised	Other-Triad Screening questionnaire Low-Income Mothers	Unchanged
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Level III Feedback Form
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Level I Feedback
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Bronze/Silver Award Application
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Gold/Gold Award of Distinction Application
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Activity Kit User Response Form
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	User Response Card
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Promote Fruits and Vegetables in Your Workplace
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Promote and Support Breastfeeding Feedback
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Event Feedback (Power Panther)
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Power Panther Request and Agreement
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Power Partner Commitment
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Kids User Response
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	Healthy Lifestyle User Response
192056	Consumer Research for Nutrition Education and Promotion Activities	Form	Unchanged	User Response Form
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Golden Grocer Award Nomination Form
192056	Consumer Research for Nutrition Education and Promotion Activities	Other-Screening Guide	Unchanged
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	FNS Core Nutrition Messags Feedback Form
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Promising Practices Submission Form
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Hunger Champions Nomination Form
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Bronze/Silver Recognizing Excellence in Nutrition and Physical Activity
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Gold Application for Recognizing Excellence in Nutrition and Physical Activity
192056	Consumer Research for Nutrition Education and Promotion Activities	Form and Instruction	Unchanged	Team Nutrition School Enrollment Form

ICR Details

OMB Control No: 0584-0524	ICR Reference No: 201207-0584-007
Status: Historical Active	Previous ICR Reference No: 201008-0584-001
Agency/Subagency: USDA/FNS	Agency Tracking No: Increase responses and burden
Title: Generic Clearance to Conduct Formative Research
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: 08/06/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/30/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	04/30/2013	04/30/2013
Responses	79,000	0	57,000
Time Burden (Hours)	33,016	0	21,016
Cost Burden (Dollars)	0	0	0

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Abstract: Information collection is necessary to obtain formative input on the development of nutrition education materials and related tools for population groups served by the U.S. Department of Agriculture

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Authorizing Statute(s): PL: Pub.L. 107 - 249 202-215 Name of Law: Emergency Food Assistance Act of 1983
   PL: Pub.L. 107 - 293 5 Name of Law: Agriculture and Consumer Protection Act of 1973
   PL: Pub.L. 108 - 269 17 Name of Law: Food Stamp Act of 1977
   PL: Pub.L. 109 - 85 17 Name of Law: Child Nutrition Act of 1966
  

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:
	74 FR 55804	10/29/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 55	03/23/2010
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 19

table that charts list of burden

IC Title	Form No.	Form Name
Consumer Research for Nutrition Education and Promotion Activities	FNS 804, FNS 805, FNS 813, FNS 807, FNS 808, FNS 809, FNS 810, FNS 811, FNS 792, FNS 812, FNS 803, FNS-793, FNS-779, FNS-780, FNS-781, FNS-791, FNS-790, FNS 780, FNS 816, FNS 779, FNS 817	Team Nutrition School Enrollment Form ,   Gold Application for Recognizing Excellence in Nutrition and Physical Activity ,   Bronze/Silver Recognizing Excellence in Nutrition and Physical Activity ,   Hunger Champions Nomination Form ,   Promising Practices Submission Form ,   FNS Core Nutrition Messags Feedback Form ,   Golden Grocer Award Nomination Form ,   User Response Form ,   Healthy Lifestyle User Response ,   Kids User Response ,   Power Partner Commitment ,   Power Panther Request and Agreement ,   Event Feedback (Power Panther) ,   Promote and Support Breastfeeding Feedback ,   Promote Fruits and Vegetables in Your Workplace ,   User Response Card ,   Activity Kit User Response Form ,   Gold/Gold Award of Distinction Application ,   Bronze/Silver Award Application ,   Level I Feedback ,   Level III Feedback Form
Core Nutrition Messages - Revised
HUSSC 2012
Healthy School Environment
MyPlate
MyPlate Parent/Student REV
Parent/Student REV 2
Request Approval to Perform Research for Team Nutrition Posters for Elementary and Middle School
Request Approval to Perform Research for Team Nutrition Posters for Elementary and Middle School
State Agencies (Prinicpal & Teachers) REV 2
Team Nutrition Curriculum (I/H)
Team Nutrition Curriculum (State Agencies: Teachers & Foodservice Staff)
Team Nutrition Curriculum Messages for 5 & 6th Grades (SA)
Team Nutrition Gardens Formative Research
Team Nutrtition Curriculum Messages for 5 & 6th Grades (I/H)
Testing the Modified FNS Core Nutrition Messages for Spanish-Speaking Audiences
What You Can Do for School Wellness Communication Tools Testing	NA, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA	NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA ,   NA
Zero Income (I/H)
Zero Income (SA)

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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	79,000	57,000	0	22,000	0	0
Annual Time Burden (Hours)	33,016	21,016	0	12,000	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: FNS is formulating related behavior-focused materials for use by consumers and stakeholders in WIC, child nutrition, SNAP and for cross-program audiences.

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Annual Cost to Federal Government: $158,333

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 07/30/2012

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