Information Collection

State, Local and/or Tribal Agencies

IC 183226 under ICR 201403-0584-003 · OMB 0584-0548.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0548 can be found here:

2014-04-22 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appx B PeerCounsBackQust Draft02-jn.doc	Other-PeerCounsBackQuest
Appx C1 DemPerProgForm.doc	Other- DemPerProgForm
Appx C2 Study Enrollment Form Draft02-jn.doc	Other-Study Enrollment Form
Appx C5 STUDY INVITATION TRACKING FORM.doc	Other-STUDY INVITATION TRACKING FORM
Appx D Contact Log Abstraction Form-jn.doc www.notcreated.com	Other-Contact Log Abstraction Form
Appx E1 LWA Staff Interview Guide 1-jn.docx	Other-LWA Staff Interview Guide
Appx E2 WICPeerC_InterviewGuide2_OMB_Draft03-jn.pdf	Other-Interview Guide 2
Appx E3 WICPeerC_InterviewGuide3_OMB_Draft03-jn.pdf	Other-nterview Guide 3
0584-0548 State Agency Survey paper 6-09 formatted.pdf mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey	Other-SA Survey Screenshot
Appx B PeerCounsBackQust FinalOMB.pdf	Other-Appx B PeerCounsBackQust Final
Appx E1 LWA Staff Interview Guide 1_FinalOMB.pdf	Other-Appx B PeerCounsBackQust Final
Appx E2 WICPeerC_InterviewGuide2_FinalOMB.pdf	Other-Appx E2 WICPeerC_InterviewGuid
Appx E3 WICPeerC_InterviewGuide3_FinalOMB.pdf	Other-Appx E3 WICPeerC_InterviewGuid
Attachment A - Phase 2 Survey.docx	Other-Attachment A: Phase 2 Survey
032514rev Attachment B Letter to Regional WIC Offices.docx	Other-032514rev Attachment B - Lette
032514rev Attachment C Letter to State WIC.docx	Other-032514rev Attachment C - Lette
Appx F1 Phase II Prelim Letter to States_5 3 11-jn.docx Phase II Prelim Letter to States	IC Document
Appx F2 FundingOppAnnounce_COMPLETE.doc Funding Opp Announce	IC Document
Appx F3 MOU_Sample-jn.docx MOU_Sample	IC Document
Appx F4 Nondisclosure.doc Nondisclosure and Confidentiality Form	IC Document
ResptoOMBTermsofClearance.doc ResptoOMBTermsofClearance	IC Document
OMB_reply_FNSfollowup Draft03 final.docx OMB_reply_FNSfollowup	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State, Local and/or Tribal Agencies

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-PeerCounsBackQuest	Appx B PeerCounsBackQust Draft02-jn.doc		No		Paper Only
Other- DemPerProgForm	Appx C1 DemPerProgForm.doc		No		Paper Only
Other-Study Enrollment Form	Appx C2 Study Enrollment Form Draft02-jn.doc		No		Paper Only
Other-STUDY INVITATION TRACKING FORM	Appx C5 STUDY INVITATION TRACKING FORM.doc		No		Paper Only
Other-Contact Log Abstraction Form	Appx D Contact Log Abstraction Form-jn.doc	www.notcreated.com	Yes	Yes	Fillable Fileable Signable
Other-LWA Staff Interview Guide	Appx E1 LWA Staff Interview Guide 1-jn.docx		No		Paper Only
Other-Interview Guide 2	Appx E2 WICPeerC_InterviewGuide2_OMB_Draft03-jn.pdf		No		Paper Only
Other-nterview Guide 3	Appx E3 WICPeerC_InterviewGuide3_OMB_Draft03-jn.pdf		No		Paper Only
Other-SA Survey Screenshot	0584-0548 State Agency Survey paper 6-09 formatted.pdf	http://mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey	Yes	Yes	Fillable Fileable Signable
Other-Appx B PeerCounsBackQust FinalOMB	Appx B PeerCounsBackQust FinalOMB.pdf		No		Paper Only
Other-Appx B PeerCounsBackQust FinalOMB	Appx E1 LWA Staff Interview Guide 1_FinalOMB.pdf		No		Paper Only
Other-Appx E2 WICPeerC_InterviewGuide2_FinalOMB	Appx E2 WICPeerC_InterviewGuide2_FinalOMB.pdf		No		Paper Only
Other-Appx E3 WICPeerC_InterviewGuide3_FinalOMB	Appx E3 WICPeerC_InterviewGuide3_FinalOMB.pdf		No		Paper Only
Other-Attachment A: Phase 2 Survey	Attachment A - Phase 2 Survey.docx		Yes	Yes	Fillable Fileable
Other-032514rev Attachment B - Letter to Regional WIC Offices	032514rev Attachment B Letter to Regional WIC Offices.docx		No		Paper Only
Other-032514rev Attachment C - Letter to StateWIC	032514rev Attachment C Letter to State WIC.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: FNS Studies and Reports - FNS 8

FR Citation: 56 FR 19079

Number of Respondents: 96

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 43 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,457	5,457
Annual IC Time Burden (Hours)	1,210	1,210
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Phase II Prelim Letter to States	Appx F1 Phase II Prelim Letter to States_5 3 11-jn.docx	11/21/2011
Funding Opp Announce	Appx F2 FundingOppAnnounce_COMPLETE.doc	07/20/2011
MOU_Sample	Appx F3 MOU_Sample-jn.docx	07/20/2011
Nondisclosure and Confidentiality Form	Appx F4 Nondisclosure.doc	07/20/2011
ResptoOMBTermsofClearance	ResptoOMBTermsofClearance.doc	11/21/2011
OMB_reply_FNSfollowup	OMB_reply_FNSfollowup Draft03 final.docx	12/01/2011

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