Communities

The Jackson Heart Study: Annual Follow-up with Third Party Respondents (NHLBI)

Documents and Forms

Document Name Document Type
Form 1 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

Information Collection (IC) Details

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:

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 %

	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

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.