CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CDC Work@Health Trainee Technical Assistance Survey	Form and Instruction	New	Available
CDC Work@Health Train-the-Trainer Technical Assistance Survey	Form and Instruction	New	Available
Rev 0920-1006 Change Request_10-10-14.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-10-14	Available
Revised Burden Table_tracked changes_10-9-14.docx	Supplementary Document	Uploaded 2014-10-13	Repair queued
Work@Health Phase 2 SS_B.doc	Supporting Statement B	Uploaded 2013-12-02	Available
PHMC IRB Determination.pdf	Supplementary Document	Uploaded 2013-12-02	Available
Att J_Work@Health Employer Training_FAQ.doc	Supplementary Document	Uploaded 2013-12-02	Repair queued
Att D_Work@Health Data Collection Flowchart.doc	Supplementary Document	Uploaded 2013-12-02	Repair queued
Att C_Program Objective - Survey Instrument Crosswalk.doc	Supplementary Document	Uploaded 2013-12-02	Available
Att B2_Summary of Public Comments.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att A3_PHSA Rsch.pdf	Supplementary Document	Uploaded 2013-12-02	Available
Att B1_Federal Register Notice.pdf	Supplementary Document	Uploaded 2013-12-02	Available
Att A2_Funding Authority_ACA.pdf	Supplementary Document	Uploaded 2013-12-02	Available
Att A1_Authorizing Legislation_EBWP.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att G-7_ScrShots of Train-the-Trainer Trainee Technical Assistance Survey.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att G-4_ ScrShots of Train-the-Trainer Participant Survey.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att G-2_ScrShots of Train-the-Trainer Application Form.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att F-8_ ScrShots of Trainee Technical Assistance Survey.docx	Supplementary Document	Uploaded 2013-12-02	Repair queued
Att F-5_ScrShots of Trainee Reaction Survey Online Model.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att F-2_ScrShots of Trainee KAB Survey.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att E-8_ScrShots of Emplr Follow-up Survey.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att E-6_ScrShots Org Assessment.docx	Supplementary Document	Uploaded 2013-12-02	Repair queued
Att E-4_ScrShots Scorecard.docx	Supplementary Document	Uploaded 2013-12-02	Available
Att E-2_ScrShots of Empr Appl Form.docx	Supplementary Document	Uploaded 2013-12-02	Available
Work@Health Phase 2 SS_A.doc	Supporting Statement A	Uploaded 2013-12-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213479	CDC Work@Health Trainee Technical Assistance Survey	Form and Instruction	New
213472	CDC Work@Health Train-the-Trainer Technical Assistance Survey	Form and Instruction	New
209594	CDC Work@Health Instructor/Coach Group Discussion Guide	Other-WORD	Unchanged
209593	CDC Work@Health Wave 2 Trainee Reaction Survey	Other-WORD	Modified
209592	CDC Word@Health Train-the Trainer Trainee Technical Assistance Survey	Other-WORD	Removed
209591	CDC Work @Health Train-the-Trainer Reaction Survey	Other-WORD	Modified
209590	CDC Work@Health Train-the-Trainer Participant Survey	Other-WORD	Modified
209589	CDC Work@Health Train-the-Trainer Application Form	Other-WORD	Modified
209588	CDC Work@Health Trainee Focus Group Discussion Guide	Other-WORD	Unchanged
209587	CDC Work @Health Case Study Interviews with Selected Trainees	Other-WORD	Unchanged
209586	CDC Work@Health Trainee Technical Assistance Survey	Other-WORD	Removed
209585	CDC Work@Health Trainee Reaction Survey Blended Model	Other-WORD	Modified
209584	CDC Work@Health Trainee Reaction Survey Online Model	Other-WORD	Unchanged
209583	CDC Work@Health Trainee Reaction Survey Hands-On Model	Other-WORD	Modified
209582	CDC Work@ Health Trainee KAB Survey	Other-WORD	Modified
209581	CDC Work@Health Case Study Interviews with Employees	Other-WORD	Unchanged
209580	CDC Work@Health Case Study Interviews with Senior Leadership	Other-WORD	Unchanged
209579	CDC Work@Health Employer Follow-up Survey	Other-WORD	Modified
209578	CDC Work Health Organizational Assessment	Other-WORD	Modified
209577	CDC Worksite Health Scorecard	Other-WORD	Modified
209576	CDC Work@Health Employer Application Form	Other-WORD	Unchanged

ICR Details

OMB Control No: 0920-1006	ICR Reference No: 201410-0920-013
Status: Historical Active	Previous ICR Reference No: 201312-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 21040
Title: CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/30/2014
	Date Received in OIRA: 10/27/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	01/31/2016	01/31/2016
Responses	5,036	0	5,066
Time Burden (Hours)	1,603	0	1,601
Cost Burden (Dollars)	0	0	0

---

Abstract: In the following Change Request for 0920-1006, CDC seeks OMB approval to increase the number of participants assigned to the train-the-trainer training model (and associated data collection), and reduce the number of participants assigned to two of the lower-demand employer training models (hands-on and blended) and associated data collections.

---

Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
   US Code: 42 USC 2801 Name of Law: Employer-based Wellness Program
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 44564	07/24/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 71615	11/29/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 19

table that charts list of burden

IC Title	Form No.	Form Name
CDC Work@Health Trainee Technical Assistance Survey	None	CDC Work@Health Trainee Technical Assistance Survey
CDC Work@Health Trainee Reaction Survey Hands-On Model
CDC Work@Health Trainee Reaction Survey Online Model
CDC Work@Health Trainee Reaction Survey Blended Model
CDC Work@Health Trainee Technical Assistance Survey
CDC Work @Health Case Study Interviews with Selected Trainees
CDC Work@Health Trainee Focus Group Discussion Guide
CDC Work@Health Train-the-Trainer Application Form
CDC Work@Health Train-the-Trainer Participant Survey
CDC Work @Health Train-the-Trainer Reaction Survey
CDC Work@Health Wave 2 Trainee Reaction Survey
CDC Work@Health Instructor/Coach Group Discussion Guide
CDC Work@Health Employer Application Form
CDC Worksite Health Scorecard
CDC Work Health Organizational Assessment
CDC Work@Health Employer Follow-up Survey
CDC Work@Health Case Study Interviews with Senior Leadership
CDC Work@Health Case Study Interviews with Employees
CDC Work@ Health Trainee KAB Survey
CDC Word@Health Train-the Trainer Trainee Technical Assistance Survey
CDC Work@Health Train-the-Trainer Technical Assistance Survey	None	CDC Work@Health Train-the-Trainer Technical Assistance Survey

---

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	5,036	5,066	0	-30	0	0
Annual Time Burden (Hours)	1,603	1,601	0	2	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Change in Burden Hours is the result of a redistribution of respondents that wish to receive a different training option.

---

Annual Cost to Federal Government: $3,515,370

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

---

Common Form ICR:  No

---

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: 10/27/2014

---