Information Collection

Communities

IC 205559 under ICR 201301-0925-002 · OMB 0925-0491.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Pre-Post Testing Forms CHAN Communities	Form and Instruction
Form 2 My Habits Pre-Post test Communities	Form and Instruction
Form 3 CHA Diary Communities	Form and Instruction
Form 4 Train the Trainer Pre-Post Test Communities	Form and Instruction
Form 5 Checklist Communities	Form and Instruction
1 Pre-Post Testing Forms CHAN Attachment 1 -Pre-Post Testing CHAN.docx	Form and Instruction
2 My Habits Pre-Post test Attachment 2-My Habits Pre-Post Test.docx	Form and Instruction
3 CHA Diary Attachment 3 - CHA Diary.doc	Form and Instruction
4 Train the Trainer Pre-Post Test Attachment 4 - Train the Trainer Pre-Post Test.docx	Form and Instruction
5 Checklist Attachment 5-Checklists.docx	Form and Instruction

IC Title:

Communities

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Pre-Post Testing Forms CHAN	Attachment 1 -Pre-Post Testing CHAN.docx	No	No	Paper Only
Form and Instruction	2	My Habits Pre-Post test	Attachment 2-My Habits Pre-Post Test.docx	No	No	Paper Only
Form and Instruction	3	CHA Diary	Attachment 3 - CHA Diary.doc	No	No	Paper Only
Form and Instruction	4	Train the Trainer Pre-Post Test	Attachment 4 - Train the Trainer Pre-Post Test.docx	No	No	Printable Only
Form and Instruction	5	Checklist	Attachment 5-Checklists.docx	No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 78

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	780	780
Annual IC Time Burden (Hours)	1,170	1,170
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.