National Healthy Worksite Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Attachment_I-2_IRB_RTIRequest_for_Exemption.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_I-1_IRB VHMRequest_for_Exemption.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Summary of Major Changes_3 06 2013.docx	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_C-5_NHWP Risk_Stratification_Logic.docx	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_C-4_NHWP_Data_Flow_Diagram_Program Provider.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_C-3_Employer_Employees_Data_Flow_Diagram_Revised_12_11_12.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_C-2_Projected Profile of NHWP Employer-Employee Participation.docx	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_C-1_NHWP_Program_Objective_Survey_Instrument_Crosswalk_Overview_and_DetailSheets.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_B-3_NHWP_Federal_Register_Notice_Program_Announcement.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_B-2_Summary of Public Comments.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_B-1_Federal_Register_Notice_60 Day.pdf	Supplementary Document	Uploaded 2013-03-26	Available
Attachment_A-2_Authorizing_Legislation_PHSA.pdf	Supplementary Document	Uploaded 2013-03-26	Available
NHWP_SS_Part_B_3_5_13.docx	Supporting Statement B	Uploaded 2013-03-26	Available
NHWP_SS_Part_A_3_5_13.docx	Supporting Statement A	Uploaded 2013-03-26	Available
Attachment_A-1_-Authorizing_Legislation.pdf	Supplementary Document	Uploaded 2013-03-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206256	All Employee Survey	Other-	New
202693	Health Screening Consent / Contact Form	Other-	Modified
202692	Nutrition and Physical Activity Tracker Log / Health Tracker	Other-	Modified
202691	Feel Fit with Fiber Challenge Log	Other-	Modified
202690	Quench Your Thirst Challenge Log	Other-	Modified
202689	Mix It Up Challenge Log	Other-	Modified
202688	Maintain Don't Gain Challenge Log	Other-	Modified
202687	Step into Health Challenge Log	Other-	Modified
202686	Lower Your Weight by Eight Challenge Log	Other-	Modified
202685	Employee Satisfaction Survey	Other-	Modified
202684	Employee Success Story Consent Form	Other-	Modified
202683	Employee Health Assessment	Other-	Modified
202682	Community Participant Emgagement Feedback Survey	Other-	Modified
202681	Worksite Health 101 Training Survey: Part IV	Other-	Modified
202680	Worksite Health 101 Training Survey: Part I-III	Other-	Modified
202679	Employer Follow-Up Survey	Other-	Modified
202678	Employer Discussion Guide: Wellness Committee (Case Studies)	Other-	Modified
202677	Employer Discussion Guide: Steering Committee Members (Case Studies)	Other-	Modified
202676	Health Screening Site Interview Form	Other-	Modified
202675	Employer Information Form	Other-	Modified
202674	Employee Eligiblity File Format Requirements	Other-	Modified
202673	Organizational Assessment (Employer)	Other-	Modified
202672	Employer Phone Interview Guide	Other-	Modified

ICR Details

OMB Control No: 0920-0965	ICR Reference No: 201303-0920-012
Status: Historical Active	Previous ICR Reference No: 201206-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No: 19147
Title: National Healthy Worksite Program
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: Approved with change	Conclusion Date: 05/13/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/26/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	36 Months From Approved
Responses	54,878	0	0
Time Burden (Hours)	17,747	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is establishing a new, comprehensive workplace health program, the National Healthy Worksite Program (NHWP). The purpose of the program is to imporve the health of workers and their families. CDC will work with employers to implement and evaluate workplace-based programs that address physical activity, nutrition, and tobacco use.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act
   US Code: 42 USC 301 Name of Law: Public Health Service Act
  

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 8874	02/15/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 39451	06/12/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 23

table that charts list of burden

IC Title	Form No.	Form Name
All Employee Survey
Community Participant Emgagement Feedback Survey
Employee Eligiblity File Format Requirements
Employee Health Assessment
Employee Satisfaction Survey
Employee Success Story Consent Form
Employer Discussion Guide: Steering Committee Members (Case Studies)
Employer Discussion Guide: Wellness Committee (Case Studies)
Employer Follow-Up Survey
Employer Information Form
Employer Phone Interview Guide
Feel Fit with Fiber Challenge Log
Health Screening Consent / Contact Form
Health Screening Site Interview Form
Lower Your Weight by Eight Challenge Log
Maintain Don't Gain Challenge Log
Mix It Up Challenge Log
Nutrition and Physical Activity Tracker Log / Health Tracker
Organizational Assessment (Employer)
Quench Your Thirst Challenge Log
Step into Health Challenge Log
Worksite Health 101 Training Survey: Part I-III
Worksite Health 101 Training Survey: Part IV

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	54,878	0	0	54,878	0	0
Annual Time Burden (Hours)	17,747	0	0	17,747	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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 information collection request supporting a new programmatic initiative. Information will be collected for program evaluation. The ICR has been revised in response to comments from OMB, HHS and DPC.

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Annual Cost to Federal Government: $1,017,108

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)? 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: 03/26/2013

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