Information Collection

Healthy School Environment

IC 195334 under ICR 201207-0584-007 · OMB 0584-0524.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0524 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
A_FNS screener_students_Revised nov30.docx	Other-Screening Questionnaire
B_FNS screener_parents_Revised nov30.docx	Other-Parent - Screening Questionnai
C_Screener_Teachers_Revised nov30.docx	Other-Teacher - Screening Questionna
D_FNS screener_principals_Revised nov30.docx	Other-Principal - Screening Question
E_Screener_Food Service Managers_Revised nov30.docx	Other-FSM - Screening Questionnaire
F_Formative Guide_Students.docx	Other-Student - Focus Group Moderato
G_Formative Guide_Parents_Revised.docx	Other-Parent - Focus Group Moderator
H_Formative Guide_Teachers_Revised.docx	Other-Teacher - Focus Group Moderato
I_Formative Guide_Principals_Revised.docx	Other-Principal - Focus Group Modera
J_Formative Guide_Food Service Managers_Revised.docx	Other-FSM - Focus Group Moderator Gu
P - Agreement on Security of Comments_Adults_Revised.docx	Other-Security Agreement - Adults
Q - Agreement on Security of Comments_parents_Revised.docx	Other-Security Agreement - Parent of
R - Parental consent form.docx	Other-Consent Form
OMB Justification Request FINAL_Revised dec20_formative only.docx Justification Memo	IC Document

IC Title:

Healthy School Environment

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Screening Questionnaire	A_FNS screener_students_Revised nov30.docx	No	Paper Only
Other-Parent - Screening Questionnaire	B_FNS screener_parents_Revised nov30.docx	No	Paper Only
Other-Teacher - Screening Questionnaire	C_Screener_Teachers_Revised nov30.docx	No	Paper Only
Other-Principal - Screening Questionnaire	D_FNS screener_principals_Revised nov30.docx	No	Paper Only
Other-FSM - Screening Questionnaire	E_Screener_Food Service Managers_Revised nov30.docx	No	Paper Only
Other-Student - Focus Group Moderator Guide	F_Formative Guide_Students.docx	No	Paper Only
Other-Parent - Focus Group Moderator Guide	G_Formative Guide_Parents_Revised.docx	No	Paper Only
Other-Teacher - Focus Group Moderator Guide	H_Formative Guide_Teachers_Revised.docx	No	Paper Only
Other-Principal - Focus Group Moderator Guide	I_Formative Guide_Principals_Revised.docx	No	Paper Only
Other-FSM - Focus Group Moderator Guide	J_Formative Guide_Food Service Managers_Revised.docx	No	Paper Only
Other-Security Agreement - Adults	P - Agreement on Security of Comments_Adults_Revised.docx	No	Paper Only
Other-Security Agreement - Parent of Children in Focus Group	Q - Agreement on Security of Comments_parents_Revised.docx	No	Paper Only
Other-Consent Form	R - Parental consent form.docx	No	Paper Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,308

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	4,308	4,308
Annual IC Time Burden (Hours)	764	764
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification Memo	OMB Justification Request FINAL_Revised dec20_formative only.docx	12/20/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.