CDC Worksite Health Scorecard

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CDC Worksite Health Scorecard	Form	New	Available
Attachment_C-4_CDC_Worksite_Health_Scorecard_Resources for Action.docx	Supplementary Document	Uploaded 2014-04-10	Available
Attachment_C-3_CDC_Worksite_Health_Scorecard_sample_benchmark_report.pdf	Supplementary Document	Uploaded 2014-04-10	Available
CDC Response to OMB questions for 0920-14BE_4-9-14.docx	Supplementary Document	Uploaded 2014-04-10	Available
0920-14BE SS_Part B 1 24 2014.doc	Supporting Statement B	Uploaded 2014-02-03	Available
Attachment D_CDC Worksite Health Scorecard FAQs_1_3_14.docx	Supplementary Document	Uploaded 2014-02-03	Available
Attachment B-2_Summary of Public Comments.doc	Supplementary Document	Uploaded 2014-02-03	Available
Attachment B-1_Federal Register Notice.pdf	Supplementary Document	Uploaded 2014-02-03	Available
Attachment A-2_Funding Authority ACA PPHF.pdf	Supplementary Document	Uploaded 2014-02-03	Available
Attachment A-1_Authorizing Legislation.docx	Supplementary Document	Uploaded 2014-02-03	Available
Attachment C-1_CDC Worksite Health Scorecard_1_24_14.docx	Supplementary Document	Uploaded 2014-02-03	Available
0920-14BE SS_Part A 1 24 2014.docx	Supporting Statement A	Uploaded 2014-02-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
210319	CDC Worksite Health Scorecard	Form	New

ICR Details

OMB Control No: 0920-1014	ICR Reference No: 201402-0920-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 21394
Title: CDC Worksite Health Scorecard
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: 04/14/2014
	Date Received in OIRA: 02/10/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved
Responses	600	0	0
Time Burden (Hours)	300	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC will collect organizational assessment information from employers to improve use of evidence-based health promotion strategies in the workplace and to evaluate changes in organizational practices over time.

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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 2801 Name of Law: Public Health and Welfare
  

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 66361	11/05/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 5413	01/31/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
CDC Worksite Health Scorecard	none	CDC Worksite Health Scorecard

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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	600	0	0	600	0	0
Annual Time Burden (Hours)	300	0	0	300	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 ICR.

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Annual Cost to Federal Government: $446,500

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? Yes

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: 02/10/2014

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