Information Collection

State, Local and/or Tribal Agencies

IC 183226 under ICR 201404-0584-010 · OMB 0584-0548.

Documents and Forms

Documents and forms in this information collection
Document NameDocument 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 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
Final_Screen Shots_edited 4-14-14.docx
mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey
Other-Final SA Survey Screenshot - O
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)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-PeerCounsBackQuest No   Paper Only
Other- DemPerProgForm No   Paper Only
Other-Study Enrollment Form No   Paper Only
Other-STUDY INVITATION TRACKING FORM No   Paper Only
Other-Contact Log Abstraction Form www.notcreated.com Yes Yes Fillable Fileable Signable
Other-LWA Staff Interview Guide No   Paper Only
Other-Interview Guide 2 No   Paper Only
Other-nterview Guide 3 No   Paper Only
Other-SA Survey Screenshot http://mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey Yes Yes Fillable Fileable Signable
Other-Appx B PeerCounsBackQust FinalOMB No   Paper Only
Other-Appx B PeerCounsBackQust FinalOMB No   Paper Only
Other-Appx E2 WICPeerC_InterviewGuide2_FinalOMB No   Paper Only
Other-Appx E3 WICPeerC_InterviewGuide3_FinalOMB No   Paper Only
Other-Attachment A: Phase 2 Survey Yes Yes Fillable Fileable
Other-032514rev Attachment B - Letter to Regional WIC Offices No   Paper Only
Other-032514rev Attachment C - Letter to StateWIC No   Paper Only
Other-Final SA Survey Screenshot - Online http://mobile.checkbox.com/abtassociates/WIC_PEERC_Intro.survey Yes Yes Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,457 0 0 0 0 5,457
Annual IC Time Burden (Hours) 1,210 0 0 0 0 1,210
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Phase II Prelim Letter to States 11/21/2011
Funding Opp Announce 07/20/2011
MOU_Sample 07/20/2011
Nondisclosure and Confidentiality Form 07/20/2011
ResptoOMBTermsofClearance 11/21/2011
OMB_reply_FNSfollowup 12/01/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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