Adoption, Health Impact and Cost of Smoke-Free Multi-Unit Housing Policies

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Outcome-oriented Focus Group	Form and Instruction	New	Available
Process-oriented Focus Group	Form and Instruction	New	Available
Pre-Focus Group Survey	Form	New	Available
Focus Group Screening	Form	New	Available
Air Quality Monitoring Protocol - Spanish	Form and Instruction	New	Available
Air Quality Monitoring Protocol	Form and Instruction	New	Available
Saliva Collection	Form and Instruction	New	Available
Resident Post-intervention - Children's Module - English	Form	New	Available
Resident Post-Intervention Survey	Form	New	Available
Resident Survey - Children's Module -LA County - Spanish	Form	New	Available
Resident Survey - Children's Module - LA County -English	Form	New	Available
Resident Baseline Survey - LA County - Spanish	Form	New	Available
Resident Baseline Survey - LA County - English	Form	New	Available
Resident Baseline Survey - screener Spanish	Form	New	Available
Resident Baseline Survey - screener - English	Form	New	Available
Recruitment Script for MUH Operators	Form and Instruction	New	Available
Post-intervention Survey	Form	New	Available
MUH Operator Baseline Survey	Form	New	Available
Recruitment Script for MUH Operators in LA County	Form and Instruction	New	Available
Supporting Statement Part B_9 10 12.docx	Supporting Statement B	Uploaded 2012-09-24	Available
Att 14_CDC IRB Approval.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 3D Logic Model_8 27 2012.doc	Supplementary Document	Uploaded 2012-09-24	Available
Att 3C_Data Collection Flow Chart.doc	Supplementary Document	Uploaded 2012-09-24	Available
Att 3B_Sources of Survey Questions.doc	Supplementary Document	Uploaded 2012-09-24	Available
Att 3A_Effect Sizes.doc	Supplementary Document	Uploaded 2012-09-24	Available
Att 2B_Summary of Public Comments.doc	Supplementary Document	Uploaded 2012-09-24	Available
Att 2A_Federal Register Notice.pdf	Supplementary Document	Uploaded 2012-09-24	Available
Att 1D_PPHF.pdf	Supplementary Document	Uploaded 2012-09-24	Available
Att 1C_Affordable Care Act.pdf	Supplementary Document	Uploaded 2012-09-24	Available
Att 1B_PHSA.docx	Supplementary Document	Uploaded 2012-09-24	Available
Att 1A_ARRA of 2009.pdf	Supplementary Document	Uploaded 2012-09-24	Available
Att 13A-1_Focus Group Consent.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 12A-2_Other Focus Group Recruitment Materials.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 12A-1_Focus Group Recruitment Flyer.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 11A-1(s)_Airborne Particle Data Diary_9 12 2012 .docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 11A-1(e)_Airborne Particle Data Diary_9 12 2012.doc	Supplementary Document	Uploaded 2012-09-27	Available
Att 10A-1(s)_Child Assent Saliva Sample_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 10A-1(e)_Child Assent Saliva Sample.docx	Supplementary Document	Uploaded 2012-09-27	Repair queued
Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-3(e)_LA Resident Consent for Child Questions.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-2(e)_LA HIPPA Form.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-27	Repair queued
Att 8A-1(e)_MUH Resident Adult Consent.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-4(s)_Resident Recruitment Materials_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-4(e)_Resident Recruitment Materials.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-3(e)_LA Resident Consent for Child Questions.docx	Supplementary Document	Uploaded 2012-09-27	Available
Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-24	Available
Att 8A-2(e)_LA HIPPA Form.docx	Supplementary Document	Uploaded 2012-09-24	Available
Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx	Supplementary Document	Uploaded 2012-09-24	Available
Att 8A-1(e)_MUH Resident Adult Consent.docx	Supplementary Document	Uploaded 2012-09-24	Available
Att 6A-1_LMUH Operator Survey Consent LA.docx	Supplementary Document	Uploaded 2012-09-24	Available
Att 6A-2_MUH Operator Survey Consent MN ME FL.docx	Supplementary Document	Uploaded 2012-09-24	Available
Att 4A-1_Letter to Property Management.docx	Supplementary Document	Uploaded 2012-09-24	Available
Supporting Statement Part A_9 10 12.docx	Supporting Statement A	Uploaded 2012-09-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204450	Focus Group - Outcome-oriented - ME, MN, FL	Form and Instruction	New	Outcome-oriented Focus Group
204449	Focus Group - Process Oriented - ME, MN, FL	Form and Instruction	New	Process-oriented Focus Group
204448	Resident Pre-Focus Group Survey - ME, MN, FL	Form	New	Pre-Focus Group Survey
204447	MUH Resident Focus Group Screening - ME, MN, FL	Form	New	Focus Group Screening
204446	Resident Air Quality Monitoring	Form and Instruction	New	Air Quality Monitoring Protocol - Spanish
204446	Resident Air Quality Monitoring	Form and Instruction	New	Air Quality Monitoring Protocol
204445	Resident Saliva Collection	Form and Instruction	New	Saliva Collection
204444	MUH Resident Post-intervention Survey - Children's Module - LA County	Form	New	Resident Post-intervention - Children's Module - English
204443	MUH Resdient Post-Intervention Survey - Core - LA County	Form	New	Resident Post-Intervention Survey
204442	MUH Resident Baseline Survey - Children's Module - LA County	Form	New	Resident Survey - Children's Module -LA County - Spanish
204442	MUH Resident Baseline Survey - Children's Module - LA County	Form	New	Resident Survey - Children's Module - LA County -English
204441	Resident Baseline Survey -Core - LA County	Form	New	Resident Baseline Survey - LA County - Spanish
204441	Resident Baseline Survey -Core - LA County	Form	New	Resident Baseline Survey - LA County - English
204440	MUH Resident Baseline Survey - screening LA county	Form	New	Resident Baseline Survey - screener Spanish
204440	MUH Resident Baseline Survey - screening LA county	Form	New	Resident Baseline Survey - screener - English
204439	Recruitment of MUH Operators in MN, ME, FL	Form and Instruction	New	Recruitment Script for MUH Operators
204438	MUH Operator Post-intervention Survey	Form	New	Post-intervention Survey
204437	MUH Operator Baseline Survey	Form	New	MUH Operator Baseline Survey
204436	Recruitment of MUH Operators in LA County	Form and Instruction	New	Recruitment Script for MUH Operators in LA County

ICR Details

OMB Control No: 0920-1004	ICR Reference No: 201210-0920-003
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Adoption, Health Impact and Cost of Smoke-Free Multi-Unit Housing Policies
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: Improperly submitted	Conclusion Date: 10/10/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/10/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		24 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC plans to conduct a quasi-experimental pretest, posttest design study with an intervention group and a comparison group to study the impact of smoke-free housing policies in multi-unit residential housing facilities. The study will include surveys of MUH operators and residents, objective measures of air quality and tobacco exposure, and focus groups with residents.

---

Authorizing Statute(s): PL: Pub.L. 111 - 5 VIII Name of Law: ARRA
   PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and ACA, Prevention and Public Health Fund
   US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 17065	03/23/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 61407	10/09/2012
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Focus Group - Outcome-oriented - ME, MN, FL	none	Outcome-oriented Focus Group
Focus Group - Process Oriented - ME, MN, FL	none	Process-oriented Focus Group
MUH Operator Baseline Survey	none	MUH Operator Baseline Survey
MUH Operator Post-intervention Survey	none	Post-intervention Survey
MUH Resdient Post-Intervention Survey - Core - LA County	none	Resident Post-Intervention Survey
MUH Resident Baseline Survey - Children's Module - LA County	none, none	Resident Survey - Children's Module - LA County -English ,   Resident Survey - Children's Module -LA County - Spanish
MUH Resident Baseline Survey - screening LA county	none, none	Resident Baseline Survey - screener - English ,   Resident Baseline Survey - screener Spanish
MUH Resident Focus Group Screening - ME, MN, FL	none	Focus Group Screening
MUH Resident Post-intervention Survey - Children's Module - LA County	none	Resident Post-intervention - Children's Module - English
Recruitment of MUH Operators in LA County	none	Recruitment Script for MUH Operators in LA County
Recruitment of MUH Operators in MN, ME, FL	none	Recruitment Script for MUH Operators
Resident Air Quality Monitoring	none, none	Air Quality Monitoring Protocol ,   Air Quality Monitoring Protocol - Spanish
Resident Baseline Survey -Core - LA County	none, none	Resident Baseline Survey - LA County - English ,   Resident Baseline Survey - LA County - Spanish
Resident Pre-Focus Group Survey - ME, MN, FL	none	Pre-Focus Group Survey
Resident Saliva Collection	none	Saliva Collection

---

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 ICR.

---

Annual Cost to Federal Government: $2,028,456

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)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 10/10/2012

---