Survey

National Survey of Community-based Policy and Environmental Supports for Healthy Eating and Active Living

Documents and Forms

Document Name Document Type
Survey Form
Survey - screenshots Appendix C2 Screenshots of Survey Questionnaire_Revised _120313..pdf Form
Survey - Word Appendix C1 CBS National Survey_Questionaire_Revised 120313.docx Form
Appendix D1 Study_Invitation_Letter_10 28 2013.docx D1 - Invitation Letter IC Document
Appendix D2 Study Fact Sheet_12032013.docx D2 - Study Fact Sheet IC Document
Appendix D3 Instructions for Accessing the Web Survey_12032013.docx D3 - Instructions for Accessing Survey IC Document

Information Collection (IC) Details

IC Title:	Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form	none	Survey - screenshots	Appendix C2 Screenshots of Survey Questionnaire_Revised _120313..pdf		Yes	Yes	Fillable Fileable
Form	none	Survey - Word	Appendix C1 CBS National Survey_Questionaire_Revised 120313.docx		No	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,139	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,139	3,139
Annual IC Time Burden (Hours)	1,570	1,570
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
D1 - Invitation Letter	Appendix D1 Study_Invitation_Letter_10 28 2013.docx	12/04/2013
D2 - Study Fact Sheet	Appendix D2 Study Fact Sheet_12032013.docx	12/04/2013
D3 - Instructions for Accessing Survey	Appendix D3 Instructions for Accessing the Web Survey_12032013.docx	12/04/2013

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