The Family Life, Activity, Sun, Health, and Eating Study (NCI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 Wear Log Instrument (Attachment L)	Form and Instruction	New	Available
Form 7 Adolescent Diet Survey Instrument (Attachment K)	Form	New	Available
Form 6 Adult Diet Survey Intrument (Attachment J)	Form	New	Available
Form 5 Adolescent Physical Activity Survey Instrument (Attachment I)	Form	New	Available
Form 4 Adult Physical Activity Survey Instrument (Attachment-H)	Form	New	Available
Form 3 Adolescent Assent Instrument (Attachment G-2)	Form	New	Available
Form 2 Parental Enrollment and Consent Instrument for Adolescent (Attachment G1)	Form	New	Available
Form 1 Parent Self-Enrollment and Consent Instrument (Attachment F)	Form	New	Available
Passback Responses to OMB_11-12-2013.doc	Supplementary Document	Uploaded 2013-11-21	Available
SSB_FLASHE.docx	Supporting Statement B	Uploaded 2013-09-05	Available
Cover Memo_9-5-2013.docx	Supplementary Document	Uploaded 2013-09-11	Available
Attach Q - References.doc	Supplementary Document	Uploaded 2013-09-05	Available
Attach P - Correspondence for Motion Study.docx	Supplementary Document	Uploaded 2013-09-05	Available
Attach O - Survey Correspondence.docx	Supplementary Document	Uploaded 2013-09-05	Available
Attach N - Emails-Website-FAQs.docx	Supplementary Document	Uploaded 2013-09-05	Available
Attach M - Study Flowchart.pdf	Supplementary Document	Uploaded 2013-09-05	Available
Attach E - IRB letters.pdf	Supplementary Document	Uploaded 2013-09-05	Available
Attach D - Westat Confidentiality Pledge.pdf	Supplementary Document	Uploaded 2013-09-05	Available
Attach C - Privacy Act Memo.pdf	Supplementary Document	Uploaded 2013-09-05	Available
Attach B - Individuals Consulted.docx	Supplementary Document	Uploaded 2013-09-05	Available
Attach A - HHS IT System PIA-FLASHE 07-26-13.pdf	Supplementary Document	Uploaded 2013-09-05	Available
SSA_FLASHE_8-30-2013.doc	Supporting Statement A	Uploaded 2013-09-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208734	Wear Log Instrument (Attachment L)	Form and Instruction	New	Wear Log Instrument (Attachment L)
208733	Adolescent Diet Survey Instrument (Attachment K)	Form	New	Adolescent Diet Survey Instrument (Attachment K)
208732	Adult Diet Survey Instrument (Attachment J)	Form	New	Adult Diet Survey Intrument (Attachment J)
208731	Adolescent Physical Activity Survey Instrument (Attachment I)	Form	New	Adolescent Physical Activity Survey Instrument (Attachment I)
208730	Adult Physical Activity Survey Instrument (Attachment H)	Form	New	Adult Physical Activity Survey Instrument (Attachment-H)
208729	Adolescent Assent Instrument (Attachment G2)	Form	New	Adolescent Assent Instrument (Attachment G-2)
208728	Parental Enrollment and Consent Instrument for Adolescent (Attachment G1)	Form	New	Parental Enrollment and Consent Instrument for Adolescent (Attachment G1)
208727	Parent Self-Enrollment and Consent Instrument (Attachment F)	Form	New	Parent Self-Enrollment and Consent Instrument (Attachment F)

ICR Details

OMB Control No: 0925-0686	ICR Reference No: 201309-0925-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No: 20481
Title: The Family Life, Activity, Sun, Health, and Eating Study (NCI)
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: 12/13/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/18/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	24 Months From Approved
Responses	11,900	0	0
Time Burden (Hours)	2,243	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The FLASHE Study takes a dyadic approach to examine psychosocial, generational (parent-adolescent), and environmental correlates of cancer preventive behaviors. FLASHE will examine the science of cancer and obesity prevention by examining correlates of cancer preventive behaviors, mainly diet, activity, and sedentary behaviors (but also examining other behaviors such as sleep, sun-safety, and tobacco) in new ways not previously addressed comprehensively on other surveys in samples of parents and their adolescent children. The survey's goal is to advance understanding of the dynamic relationship between the environment, psychosocial factors, and cancer preventive behaviors from a dyadic perspective. Data collected will ultimately be a public use dataset and resource to the research community. FLASHE will be collecting data from parents and their adolescent children using a web survey format with a final estimated sample size of 2,500 dyads, with motion sensing data collected in a subsample of 900 adolescents.

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Authorizing Statute(s): US Code: 42 USC 412 (285a-1) Name of Law: Public Health Service Act
   US Code: 42 USC 413 (285a-2) 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:
	78 FR 38996	06/28/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 56901	09/16/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Adolescent Assent Instrument (Attachment G2)	3	Adolescent Assent Instrument (Attachment G-2)
Adolescent Diet Survey Instrument (Attachment K)	7	Adolescent Diet Survey Instrument (Attachment K)
Adolescent Physical Activity Survey Instrument (Attachment I)	5	Adolescent Physical Activity Survey Instrument (Attachment I)
Adult Diet Survey Instrument (Attachment J)	6	Adult Diet Survey Intrument (Attachment J)
Adult Physical Activity Survey Instrument (Attachment H)	4	Adult Physical Activity Survey Instrument (Attachment-H)
Parent Self-Enrollment and Consent Instrument (Attachment F)	1	Parent Self-Enrollment and Consent Instrument (Attachment F)
Parental Enrollment and Consent Instrument for Adolescent (Attachment G1)	2	Parental Enrollment and Consent Instrument for Adolescent (Attachment G1)
Wear Log Instrument (Attachment L)	8	Wear Log Instrument (Attachment L)

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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	11,900	0	0	11,900	0	0
Annual Time Burden (Hours)	2,243	0	0	2,243	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.

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Annual Cost to Federal Government: $505,000

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]? No

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: 09/18/2013

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