CDC Work@Health Program: Phase 1

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Train-the-Trainer Evaluation Survey	Form	New	Available
Blended Evaluation Survey	Form	New	Available
Online Pilot Screenshots	Form	New	Available
Pilot Training Hands On	Form	New	Available
Pilot Employer Application Form	Form	New	Available
Training Needs Assessment	Form	New	Available
Work@Health Pilot SS B 7-17-13.doc	Supporting Statement B	Uploaded 2013-07-25	Available
Attachment J_FAQ_7-05-13.doc	Supplementary Document	Uploaded 2013-07-25	Available
Attachment C_Objectives-Crosswalk of Instruments_6-25-13.doc	Supplementary Document	Uploaded 2013-07-25	Available
Attachment B-2_Summary of Public Comments.docx	Supplementary Document	Uploaded 2013-07-25	Available
Attachment B-1_Federal Register Notice_60 Day.pdf	Supplementary Document	Uploaded 2013-07-25	Available
Attachment A-2_Funding Authority.pdf	Supplementary Document	Uploaded 2013-07-25	Available
Attachment A-1_Authorizing Legislation.docx	Supplementary Document	Uploaded 2013-07-25	Available
Attachment F-1_Online Eval Survey_6-25-13.doc	Supplementary Document	Uploaded 2013-07-25	Available
Attachment I-1_Pilot Employer Application Form_6-25-13.doc	Supplementary Document	Uploaded 2013-07-25	Available
Attachment D-1_Training Needs Assessment Survey_6-25-13.doc	Supplementary Document	Uploaded 2013-07-25	Available
Work@Health Pilot SS A 7-17-13.doc	Supporting Statement A	Uploaded 2013-07-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208010	Participating Employer - Pilot Training: Train-the-Trainer Evaluation Survey	Form	New	Train-the-Trainer Evaluation Survey
208009	Participating Employer - Pilot Training: Blended Model Evaluation Survey	Form	New	Blended Evaluation Survey
208008	Participating Employer - Pilot Training: Online Model Evaluation Survey	Form	New	Online Pilot Screenshots
208007	Interested Employer - Pilot Training Hands-on Model Evaluation Survey	Form	New	Pilot Training Hands On
208006	Interested Employer - Pilot Employer Application Form	Form	New	Pilot Employer Application Form
208005	Interested Employer - Training Needs Assessment Survey	Form	New	Training Needs Assessment

ICR Details

OMB Control No: 0920-0989	ICR Reference No: 201308-0920-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 20160
Title: CDC Work@Health Program: Phase 1
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 without change	Conclusion Date: 09/23/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/01/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	12 Months From Approved
Responses	660	0	0
Time Burden (Hours)	117	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC plans to conduct employer training needs assessment survey and an evaluation of pilot training models prior to implementing a full scale Work@Health training program.

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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
   US Code: 42 USC 2801 Name of Law: Employer-based Wellness Program
  

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:
	78 FR 28850	05/16/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 44566	07/24/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Interested Employer - Pilot Employer Application Form	none	Pilot Employer Application Form
Interested Employer - Pilot Training Hands-on Model Evaluation Survey	none	Pilot Training Hands On
Interested Employer - Training Needs Assessment Survey	none	Training Needs Assessment
Participating Employer - Pilot Training: Blended Model Evaluation Survey	none	Blended Evaluation Survey
Participating Employer - Pilot Training: Online Model Evaluation Survey	none	Online Pilot Screenshots
Participating Employer - Pilot Training: Train-the-Trainer Evaluation Survey	none	Train-the-Trainer Evaluation Survey

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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	660	0	0	660	0	0
Annual Time Burden (Hours)	117	0	0	117	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.

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Annual Cost to Federal Government: $1,642,892

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? No

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: 08/01/2013

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