Employee Success Story Consent Form

National Healthy Worksite Program

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Employee Success Story Consent Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.