Information Collection

Healthy Weight Collaborative

IC 204420 under ICR 201210-0915-001 · OMB 0915-0358.

Documents and Forms

Document Name Document Type
Form 1 Healthy Weight Collaborative Form
Informed Consent Form - Final 11-28-12.docx Other-Interview Consent
1 Phase 1 interviews Phase 1 community team interviews.docx Form
2 Phase 2 Phase 2 Community Team Interviews.docx Form
3 NICHQ Phase 2 NICHQ Leadership.docx Form
4 observation template learning session observation template.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Healthy Weight Collaborative	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Phase 1 interviews	Phase 1 community team interviews.docx	No	No	Paper Only
Form	2	Phase 2	Phase 2 Community Team Interviews.docx	Yes	Yes	Paper Only
Form	3	NICHQ	Phase 2 NICHQ Leadership.docx	Yes	Yes	Paper Only
Form	4	observation template	learning session observation template.docx	Yes	Yes	Paper Only
Other-Interview Consent			Informed Consent Form - Final 11-28-12.docx	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 103	Number of Respondents for Small Entity: 84

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	103	103
Annual IC Time Burden (Hours)	136	136
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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