| Respondent Type |
Respondent Description |
Type of Survey Instrument |
Appendices |
Sample size (a) |
Number of Respondents |
Frequency of Response (annual) |
Total Annual Responses |
Average Hours per Response |
Sub- Annual Burden |
Number of non -respondents |
Frequency of Response (annual) |
Total Annual Responses |
Average Hours per response |
Sub-Total Annual Burden |
Total Burden Hours |
Hourly Rate |
Total Annualized Cost |
| Individuals and Households |
WIC participants |
Pretest telephone survey |
A |
4 |
4 |
1 |
4 |
0.5 |
2 |
0 |
1 |
0 |
0.5 |
0 |
2 |
$7.25 |
$14.50 |
| Advance materials: flyer (b) |
B |
4,046 |
3,237 |
1 |
3,237 |
0.008 |
25.90 |
809 |
1 |
809 |
0.008 |
6.47 |
32.37 |
$7.25 |
$234.67 |
| Advance materials: Consent form & contact info (b) |
C |
4,046 |
3,115 |
1 |
3,115 |
0.1336 |
416.16 |
931 |
1 |
931 |
0.1336 |
124.38 |
540.55 |
$7.25 |
$3,918.96 |
| 24-mo survey: contact information module |
D |
4,046 |
2,716 |
1 |
2,716 |
0.0501 |
136.1 |
1,330 |
1 |
1,330 |
0 |
0 |
136.1 |
$7.25 |
$986.52 |
| 27-mo contact information form (c) |
E |
3,277 |
2,294 |
1 |
2,294 |
0.1002 |
229.9 |
983 |
1 |
983 |
0.1002 |
98.5 |
328.4 |
$7.25 |
$2,380.58 |
| 30-mo advance letter (c) |
F |
3,277 |
2,785 |
1 |
2,785 |
0.0334 |
93.0 |
492 |
1 |
492 |
0.0334 |
16.43 |
109.45 |
$7.25 |
$793.53 |
| 30-mo telephone survey(d) |
G |
4,046 |
2,580 |
1 |
2,580 |
0.5 |
1,290 |
1466 |
1 |
1466 |
0 |
0 |
1290 |
$7.25 |
$9,352.50 |
| Participant reminder scripts (e) |
H |
1,638 |
1,638 |
3 |
4,914 |
0.0501 |
246.2 |
0 |
3 |
0 |
0.0501 |
0 |
246.2 |
$7.25 |
$1,784.89 |
| 33 mo contact information form (f) |
E |
3,113 |
2,179 |
1 |
2,179 |
0.1002 |
218.3 |
934 |
1 |
934 |
0.1002 |
93.6 |
311.9 |
$7.25 |
$2,261.44 |
| 36-mo advance letter (f) |
I |
3,113 |
2,646 |
1 |
2,646 |
0.0334 |
88.38 |
467 |
1 |
467 |
0.0334 |
15.60 |
103.97 |
$7.25 |
$753.81 |
| 36-mo telephone survey (g) |
J |
4,046 |
2,444 |
1 |
2,444 |
0.5 |
1,222 |
1602 |
1 |
1602 |
0 |
0 |
1222 |
$7.25 |
$8,859.50 |
| HIPAA form (g) |
V |
244 |
196 |
1 |
196 |
0.0501 |
9.82 |
48 |
1 |
48 |
0.0501 |
2.40 |
12.22 |
$7.25 |
$88.63 |
| HT/WT measurement card (h) |
U |
978 |
685 |
1 |
685 |
1 |
685 |
293 |
1 |
293 |
0 |
0 |
685 |
$7.25 |
$4,966.25 |
| Birthday card |
K |
3,277 |
3,277 |
1 |
3,277 |
0.003 |
9.83 |
0 |
1 |
0 |
0.003 |
0.00 |
9.83 |
$7.25 |
$71.27 |
| Individuals and Households Subtotal |
|
4,050 |
3,281 |
|
33,072 |
|
4,672.56 |
769.00 |
|
9,355 |
|
357.37 |
5,029.94 |
|
$36,467.04 |
| State & Local Government |
State WIC data manager |
Communication materials (i) |
M-P |
27 |
27 |
1 |
27 |
0.55 |
14.85 |
0 |
1 |
0 |
0.55 |
0 |
14.85 |
$53.15 |
$789.28 |
| HT/WT Admin data form (j) |
O |
27 |
27 |
1 |
27 |
0.5 |
13.5 |
0 |
1 |
0 |
0.5 |
0 |
13.5 |
$53.15 |
$717.53 |
| Subtotal |
|
27 |
27 |
|
54 |
|
28.35 |
0 |
|
0 |
|
0 |
28.35 |
|
$1,506.80 |
| WIC site staff |
Communication materials (i) |
Q-T |
80 |
80 |
1 |
80 |
0.55 |
44 |
0 |
1 |
0 |
0.55 |
0 |
44 |
$13.61 |
$598.84 |
| Request for contact information (k) |
L |
80 |
80 |
20 |
1,600 |
0.0835 |
133.6 |
0 |
20 |
0 |
0.0835 |
0 |
133.6 |
$13.61 |
$1,818.30 |
| HT/WT measurement (l) |
V |
80 |
80 |
9 |
720 |
0.2171 |
156.31 |
0 |
9 |
0 |
0.2171 |
0 |
156.31 |
$13.61 |
$2,127.41 |
| Subtotal |
|
80 |
80 |
|
2,400 |
|
333.91 |
0 |
|
0 |
|
0 |
333.91 |
|
$4,544.54 |
| State/Local Government Subtotal |
|
107 |
107 |
|
2,454 |
|
362.26 |
0 |
|
0 |
|
0 |
362.26 |
|
$6,051.34 |
| Profit/Non-Profit Business |
Provider data manager |
Provider Data Request Form (m) |
W |
196 |
157 |
1 |
157 |
0.0835 |
13.11 |
39 |
1 |
39 |
0.0835 |
3.26 |
16.37 |
$13.61 |
$222.74 |
| Profit/Non-Profit Business Subtotal |
|
196 |
157 |
|
157 |
|
13.11 |
39 |
|
39 |
|
3.26 |
16.37 |
|
$222.74 |
| GRAND TOTAL |
|
4,353 |
3,545 |
|
35,683 |
|
5,047.94 |
808 |
|
9,394.00 |
|
360.63 |
5,408.56 |
|
$42,741.12 |
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| (a) 4046 = base study total live birth cohort |
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| (b) Assume 80% will read flyer and 77% will sign consent form |
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| (c) Of base study total live birth cohort -- assume about 67% will complete 24-month survey, 64% will complete 30-month survey, 60% will complete 36-month survey |
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| (d) Assume study attrition from current cohort will be 10% per year x 2 years = 4,046*.9*.9 = 3,277 at end of 24-months. Assume 70% will complete the contact information form and 85% will read the advance letter. |
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| (e) Assume 50% of cohort at 24-months will require reminders (e.g., telephone, email, text). Assume average of 3 contacts each |
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| (f) Assume study attrition @ 33-month will be 5%. 4046*.9*.9*.95 = 3113. Assume 70% will return contact information form and 85% will read advance letter. |
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| (g) Assume 10% of respondents to 36-month interview will no longer be on WIC and will need HIPAA to collect H/W measurements from provider. Of those, about 80% will sign and return the form. |
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| (h) Assume 40% of respondents to the 36-month interview will no longer be on WIC but will be able to visit their WIC site for H/W measurement; of those, 70% will be measured. Assume 1 hour for reading letter, travel to/from WIC site, and measuring child. |
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| (i) Includes reviewing one email (5 minutes) and participating in a conference call (30 minutes) |
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| (j) Assume administrative H/W records will be provided by State WIC office 1 time. |
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| (k) Assume will request participant contact information from WIC sites about once a month over the data collection period. |
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| (l) Assume that for the 40% participants no longer on WIC and returning to WIC site for measurements, about 9 children will be weighed and measured per site. Assume 10 minutes for measurements and 3 minutes for data transfer, for a total of 13 minutes per child. |
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| (m) Assume H/W data for participants who returned HIPAA form will be provided by 80% of providers. |
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