Information Collection

Employee Success Story Consent Form

IC 202684 under ICR 201303-0920-012 · OMB 0920-0965.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_F-3_NHWP_Success_Story_Consent_Form.docx	Other-null
Attachment_F-4_NHWP_Satisfaction Survey.docx Attachment_F-4_NHWP_Satisfaction Survey	IC Document
Attachment_H-1_NHWP_Community_Director_Discussion_Guide.docx Attachment_H-1_NHWP_Community_Director_Discussion_Guide	IC Document
Attachment_H-2_NHWP_Health_Coach_Discussion_Guide.docx Attachment_H-2_NHWP_Health_Coach_Discussion_Guide	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-null			Attachment_F-3_NHWP_Success_Story_Consent_Form.docx		No		Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 76

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	76	76
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment_F-4_NHWP_Satisfaction Survey	Attachment_F-4_NHWP_Satisfaction Survey.docx	03/26/2013
Attachment_H-1_NHWP_Community_Director_Discussion_Guide	Attachment_H-1_NHWP_Community_Director_Discussion_Guide.docx	03/26/2013
Attachment_H-2_NHWP_Health_Coach_Discussion_Guide	Attachment_H-2_NHWP_Health_Coach_Discussion_Guide.docx	03/26/2013

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