Information Collection Request

The Healthy Communities Study: How Communities Shape Childrens Health (NHLBI)

ICR 201307-0925-004 · OMB 0925-0649 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 13 School Physical Activity and Nutrition Policies and Form and Instruction New Available
Form 11 School Food Environment Instrument Form and Instruction New Available
Form 8 Medical Record Retrieval Form and Instruction Modified Available
Form 1 Health Department Script Form and Instruction Removed Available
Form 10 PARA Form and Instruction Modified Available
Form 9 School Lunch Observations Form and Instruction Modified Available
Form 7 Key Informant Interview Protocol Form and Instruction Modified Available
Form 6 KI Screening Protocol Overview Form and Instruction Modified Available
Form 5 Family Household Visit Protocol Overiview for Child Form and Instruction Modified Available
Form 4 Parents/Caregivers (who refuse) Form and Instruction Modified Available
Form 3 Family Household Visit Protocol Overview Form and Instruction Modified Available
Form 2 Family Household Visit Protocol Overview Form and Instruction Modified Available
Form 1 Family Screener Form and Instruction Modified Available
FINAL_HCS_SSB_7-11-13.docx Supporting Statement B Uploaded 2013-07-24 Available
FINAL_HCS_SSB_ATTACH 2_NOMINATION FORM_Jan 2013.xlsx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSB_ATTACH 1_CCSC MEMBERS_Jan 2013.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 1_GLOSSARY_Jan 2013.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 2_BEE ROSTER_SEP 2011.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 3_NHLBI COUNCIL ROSTER_SEP 2011.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 4_TOOLKIT_Jan 2013.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 21_NCCOR LETTER_Jan 2013.pdf Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 22_SUBCOMMITTEES_Jan 2013.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 23_IRB APPROVAL_Jan 2013.pdf Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 24_PRIVACY ACT MEMO_Jan 2013.pdf Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 14_MOD WINDSHIELD SURVEY_Jan 2013.docx Supplementary Document Uploaded 2013-07-24 Available
HCS_OMB Memo RE revision_2-12-13 revised 2 28 13.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSB_ATTACH 3_STAT POWER ANALYSIS_July 2013.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 10_KI LETTER_Jan 2013.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_ATTACH 11_KI BROCHURE_Jan 2013.docx Supplementary Document Uploaded 2013-07-24 Available
FINAL_HCS_SSA_7-11-13.docx Supporting Statement A Uploaded 2013-07-24 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
207892 School Liaisons Form and Instruction NewSchool Physical Activity and Nutrition Policies and
207891 District Food Service Administrator/Manager Form and Instruction NewSchool Food Environment Instrument
199554 Physicians/Medical Secretaries Form and Instruction ModifiedMedical Record Retrieval
199553 State Health Department Employees Form and Instruction RemovedHealth Department Script
199552 Physical Education Instructiors Form and Instruction ModifiedPARA
199551 Food Service Personnel Form and Instruction ModifiedSchool Lunch Observations
199550 Key Informants Form and Instruction ModifiedKey Informant Interview Protocol
199549 Key Informats (screening) Form and Instruction ModifiedKI Screening Protocol Overview
199548 Children Form and Instruction ModifiedFamily Household Visit Protocol Overiview for Child
199547 Parents/Caregivers (who refused) Form and Instruction ModifiedParents/Caregivers (who refuse)
199546 Second Parents Form and Instruction ModifiedFamily Household Visit Protocol Overview
199545 Parents/Caregivers Form and Instruction ModifiedFamily Household Visit Protocol Overview
199544 Parents (screening) Form and Instruction ModifiedFamily Screener

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2016 36 Months From Approved 01/31/2015
69,010 0 90,880
29,505 0 33,145
0 0 0





Reginfo record details
12
table that charts list of burden
IC Title Form No. Form Name
Children 5
District Food Service Administrator/Manager 11
Food Service Personnel 9
Key Informants 7
Key Informats (screening) 6
Parents (screening) 1
Parents/Caregivers 2
Parents/Caregivers (who refused) 4
Physical Education Instructiors 10
Physicians/Medical Secretaries 8
School Liaisons 13
Second Parents 3
State Health Department Employees 1

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 69,010 90,880 0 0 -21,870 0
Annual Time Burden (Hours) 29,505 33,145 0 0 -3,640 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No