Revised Burden Table

OMB #0920-1006 Revised Burden Table (changes are noted in parentheses)

Estimated Annualized Burden Hours and Cost to Respondents

Table A. Estimated Annualized Burden Hours

Type of Respondent	Form Name	Number of Respondents (and change)	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Burden in hours (and change)
Interested Employer	Employer Application Form	600	1	20/60	200
Employers Participating in Work@Health™	CDC Worksite Health Scorecard	480 (-60)	1	0.5	240 (-30)
	Organizational Assessment	480 (-60)	1	15/60	120 (-15)
	Employer Follow-up Survey	240 (-30)	1	15/60	60 (-8)
	Case Study Interviews with Senior Leadership	3	1	1	3
	Case Study Interviews with Employees	6	1	1	6
Trainees Participating in the Work@Health™ Program (Hands-on, Online, Blended models)	Trainee KAB Survey	960 (-120)	1	20/60	320 (-40)
	Trainee Reaction Survey – Hands-On Model	150 (-30)	1	15/60	38 (-7)
	Trainee Reaction Survey – Online Model	180	1	15/60	45
	Trainee Reaction Survey – Blended Model	150 (-30)	1	15/60	38 (-7)
	Trainee Technical Assistance Survey	960 (-120)	1	15/60	240 (-30)
	Case Study Interviews with Selected Trainees	15	1	1	15
	Trainee Focus Group Discussion Guide	11	1	1.5	17
Interested Train-the-Trainer Participants	Train-the-Trainer Application Form	180 (+120)	1	0.5	90 (+60)
Trainees Participating in the Work@Health™ Program (Train-the-Trainer model)	Train-the-Trainer Participant Survey	120 (+60)	1	20/60	40 (+20)
	Trainee Reaction Survey – Train-the-Trainer Model	60 (+30)	1	15/60	15 (+7)
	Train-the-Trainer Trainee Technical Assistance Survey	120 (+60)	1	15/60	30 (+15)
Trainees participating in the Work@Health™ Program Wave 2	Wave 2 Trainee Reaction Survey	300 (+150)	1	15/60	75 (+37)
Work@HealthTM Instructors/Coaches	Instructor/Coach Group Discussion Guide	21	1	0.5	11
Total					1,603 (+2)