Targeted Surveillance and Biometric Studies for Enhanced Evaluation of CTGs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Adult Targeted Surveillance Survey Recruitment Screener	Form	New	Available
Youth Survey	Form	New	Available
Youth Survey Recruitment Screener for Youth	Form	New	Available
Youth Activity Diary	Form	New	Available
Child or Youth Biometric Measures	Form	New	Available
Caregiver Activity Diary (on behalf of young child)	Form	New	Available
Caregiver Survey	Form	New	Available
Caregiver Survey Recruitment Screener	Form	New	Available
Adult Activity Diary and Reminder	Form	New	Available
Adult Biometric Measures	Form	New	Available
Youth Survey Recruitment Screener for Parent/Guardian	Form	New	Available
Adult Biometric Measures Recruitment Screener (In-person)	Form	New	Available
Adult Biometric Measures Recruitment Screener (phone/paper)	Form	New	Available
Adult Targeted Surveillance Survey	Form	New	Available
0920-12IG_Part_B_7-23-12.doc	Supporting Statement B	Uploaded 2012-08-07	Available
Att S6B_Consent (Phone) Spanish.docx	Supplementary Document	Uploaded 2012-08-07	Available
Att S6A_Consent (Paper) Spanish.docx	Supplementary Document	Uploaded 2012-08-07	Available
Att S11B_ATSS_Postcard Spanish.doc	Supplementary Document	Uploaded 2012-08-07	Available
Att 11B_ATSS_ReminderPostcard.doc	Supplementary Document	Uploaded 2012-08-07	Available
Att S11A_ATSS_LeadLetterSpanish.doc	Supplementary Document	Uploaded 2012-08-07	Available
Att 11A_ATSS_LeadLetter.doc	Supplementary Document	Uploaded 2012-08-07	Available
Att 7_DataCollectionFlow04.wmf	Supplementary Document	Uploaded 2012-08-07	Repair queued
Att 6B_ATSS_Consent(Phone).doc	Supplementary Document	Uploaded 2012-08-01	Available
Att 6A_Consent(Paper).doc	Supplementary Document	Uploaded 2012-08-01	Available
Att 5_DataSources.doc	Supplementary Document	Uploaded 2012-08-01	Available
Att 4C_ListofCTGAwardees.docx	Supplementary Document	Uploaded 2012-07-26	Available
Att 4B_CTGEvaluationPlan.doc	Supplementary Document	Uploaded 2012-07-26	Available
Att 4A_StrategicDirections.docx	Supplementary Document	Uploaded 2012-07-26	Available
Att 3B_IRBApproval_YABS.pdf	Supplementary Document	Uploaded 2012-07-26	Available
Att 3A_IRBApproval_ATSS.pdf	Supplementary Document	Uploaded 2012-07-26	Available
Att 2_60-dayFRN.pdf	Supplementary Document	Uploaded 2012-07-26	Available
Att 1B_ACASection4201.doc	Supplementary Document	Uploaded 2012-07-26	Repair queued
Att 1A_PHSA.pdf	Supplementary Document	Uploaded 2012-07-26	Available
Att S13A_Accelerometry Instructions Spanish.docx	Supplementary Document	Uploaded 2012-08-07	Available
Att 13A_Accelerometry Instructions.docx	Supplementary Document	Uploaded 2012-08-07	Available
Att S8B_ATSS FAQGuide Spanish.doc	Supplementary Document	Uploaded 2012-08-07	Available
Att 8B_ATSS_FAQGuide.docx	Supplementary Document	Uploaded 2012-08-07	Available
0920-12IG_Part_A_7-23-12.doc	Supporting Statement A	Uploaded 2012-08-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203638	Adult Targeted Surveillance Survey Recruitment Screener	Form	New
203637	Youth Survey	Form	New
203636	Youth Survey Recruitment Screener for Youth	Form	New
203635	Youth Activity Diary	Form	New
203634	Child or Youth Biometric Measures	Form	New
203633	Caregiver Activity Diary (on behalf of young child)	Form	New
203632	Caregiver Survey	Form	New
203631	Caregiver Survey Recruitment Screener	Form	New
203630	Adult Activity Diary and Reminder	Form	New
203629	Adult Biometric Measures	Form	New
203628	Youth Survey Recruitment Screener for Parent/Guardian	Form	New
203627	Adult Biometric Measures Recruitment Screener (In-person)	Form	New
203626	Adult Biometric Measures Recruitment Screener (phone/paper)	Form	New
203625	Adult Targeted Surveillance Survey	Form	New

ICR Details

OMB Control No: 0920-0977	ICR Reference No: 201208-0920-003
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Targeted Surveillance and Biometric Studies for Enhanced Evaluation of CTGs
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: 11/19/2012
	Date Received in OIRA: 08/07/2012
Terms of Clearance: Withdrawn as discussed on 11/19/2012 call.

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 requests approval to collect information to analyze trends in behavioral and biometric indicators of risk factors for chronic disease in communities funded through the Community Transformation Grant (CTG) Program. Priority will be given to assessment of weight, diet, physical activity, tobacco use, and exposure to secondhand smoke in CTG-funded communities.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
   US Code: 4 USC 4201 Name of Law: Community Transformation Grants
  

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 23263	04/18/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47073	08/07/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Caregiver Survey Recruitment Screener	none, none	Caregiver Screener ,   Spanish Caregiver Screener
Adult Targeted Surveillance Survey	none, none	Adult Targeted Survey ,   Spanish Adult Targeted Survey
Adult Biometric Measures Recruitment Screener (phone/paper)	none, none	Biometric Screener ,   Spanish Biometric Screener
Adult Biometric Measures Recruitment Screener (In-person)	none, none	Biometric Screener in-person ,   Spanish Biometric Screener in-person
Youth Survey Recruitment Screener for Parent/Guardian	none, none	Youth Survey Recruitment Screener for Parent ,   Spanish Youth Survey Recruitment Screener for Parent
Adult Biometric Measures	none, none	Adult Biometric Measures ,   Spanish Adult Biometric Measures
Adult Activity Diary and Reminder	none, none	Adult Activity Diary ,   Spanish Adult Activity Diary
Caregiver Survey	none, none	Caregiver Survey ,   Spanish Caregiver Survey
Caregiver Activity Diary (on behalf of young child)	none, none	Youth Caregiver Activity Diary ,   Spanish Youth Caregiver Activity Diary
Child or Youth Biometric Measures	none, none, none, none	Biometric Measures Age 12-17 ,   Biometric Measures Ages 3-11 ,   Spanish Biometric Measure Age 12-17 ,   Spanish Biometric Measure Age 3-11
Youth Activity Diary	none, none	Youth Activity Diary ,   Spanish Youth Activity Diary
Youth Survey Recruitment Screener for Youth	none, none	Survey Recruitment Screener for Youth ,   Spanish Survey Recruitment Screener for Youth
Youth Survey	none, none	Youth Survey ,   Spanish - Youth Survey
Adult Targeted Surveillance Survey Recruitment Screener	none, none	Adult Targeted Survey Screener ,   Spanish Adult Targeted Survey Screener

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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 ACA related data collection supporting evaluation of a new programmatic initiative.

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Annual Cost to Federal Government: $5,037,366

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]? 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: 08/07/2012

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