Information Collection

I/H WIC Participants

IC 198544 under ICR 201404-0584-010 · OMB 0584-0548.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appx A1 WICPeerC Baseline Survey_draft02-jn.docx	Other-Baseline Survey
Appx A2 WIC PeerC Followup Survey_draft03-jn.pdf	Other-Followup Survey
Appx A3 Baseline Survey_SpanishOMBDraft02-jn.doc	Other-Baseline Survey_Spanish
Appx A4 Followup Survey_SpanishOMBDraft02-jn.doc	Other-Followup Survey_SpanishOMB
Appx C3 DECLINE form-jn.docx	Other-Decline form (English)
Appx C4 DECLINE form Spanish__postGG-jn.docx	Other-Decline Form (Spanish)
Appx C5 STUDY INVITATION TRACKING FORM.doc	Other-Study Invitation Tracking Form
Appx C6 RefusalWithdraw.doc	Other-Refusal/Withdraw Form
Appx F6 Consent Form_ready.doc	Other-Consent Form
Appx A2 WIC PeerC Followup Survey_FinalOMB.pdf	Other-Appx A2 WIC PeerC Followup Sur
Appx F6 Consent Form_ready.pdf	Other-Peer Counseling Study\2011 rev
Appx F5 Study Brochure_AllPages.pdf Brochure	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Baseline Survey	Appx A1 WICPeerC Baseline Survey_draft02-jn.docx	No	Paper Only
Other-Followup Survey	Appx A2 WIC PeerC Followup Survey_draft03-jn.pdf	No	Paper Only
Other-Baseline Survey_Spanish	Appx A3 Baseline Survey_SpanishOMBDraft02-jn.doc	No	Paper Only
Other-Followup Survey_SpanishOMB	Appx A4 Followup Survey_SpanishOMBDraft02-jn.doc	No	Paper Only
Other-Consent Form	Appx F6 Consent Form_ready.doc	No	Paper Only
Other-Appx A2 WIC PeerC Followup Survey	Appx A2 WIC PeerC Followup Survey_FinalOMB.pdf	No	Paper Only
Other-Peer Counseling Study\2011 revised 11-30-11\Appx F6 Consent Form	Appx F6 Consent Form_ready.pdf	No	Paper Only
Other-Decline form (English)	Appx C3 DECLINE form-jn.docx	No	Paper Only
Other-Decline Form (Spanish)	Appx C4 DECLINE form Spanish__postGG-jn.docx	No	Paper Only
Other-Study Invitation Tracking Form	Appx C5 STUDY INVITATION TRACKING FORM.doc	No	Paper Only
Other-Refusal/Withdraw Form	Appx C6 RefusalWithdraw.doc	No	Paper Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: FNS Studies and Reports - FNS 8

FR Citation: 56 FR 19079

Number of Respondents: 1,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,600	3,600
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Brochure	Appx F5 Study Brochure_AllPages.pdf	11/21/2011

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