Application of a Web-based health Survey In Schools

Forms and Documents

Document Name	Status
Non-Respondent Survey Questionnaire Form and Instruction	Modified
School Health Queationnaire Form and Instruction	Modified
OMB_0920-1047_Change Request.docx Justification for No Material/Nonsubstantive Change	2015-02-23
OMB_schools_AppendixI_reminder.docx Supplementary Document	2014-10-09
OMB_schools_AppendixH_announcement.docx Supplementary Document	2014-10-09
OMB_schools_AppendixG_Invitation.docx Supplementary Document	2014-10-09
OMB_schools_AppendixF_IRBLetter.docx Supplementary Document	2014-10-09
App B_Published 60d FRN.pdf Supplementary Document	2014-10-09
OMB_schools_AppendixA_Law.docx Supplementary Document	2014-10-09
SupSta B_14AC.docx Supporting Statement B	2014-10-09
SupSta A_14AC.docx Supporting Statement A	2014-10-09

IC Document Collections

IC ID	Document Title	Status
213408	Non-Respondent Survey Questionnaire Form and Instruction	Modified
213407	School Health Queationnaire Form and Instruction	Modified

ICR Details

OMB Control No: 0920-1047	ICR Reference No: 201502-0920-014
Status: Historical Active	Previous ICR Reference No: 201410-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 15QF
Title: Application of a Web-based health Survey In Schools
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: 03/06/2015
	Date Received in OIRA: 03/02/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	01/31/2016	01/31/2016
Responses	3,600	0	3,600
Time Burden (Hours)	1,100	0	1,100
Cost Burden (Dollars)	0	0	0

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Abstract: This Non-Substantive Change request is being submitted to add a single question designed to collect the zip code of residence for each respondent. The question will be added to both the Main survey instrument and non-respondent questionnaire and will provide insight into the socioeconomic status and housing density of the study population and will allow us to stratify analyses by geographic location. The National Institute for Occupational Safety and Health (NIOSH) is conducting a health questionnaire of employees in 50 elementary schools in a large urban school district as part of the PHP-funded research project, Application of a Web-Based Health Survey Tool in Schools. The purpose of this project is to better understand how associations between health outcomes and dampness/mold scores can be used to prioritize remediation in schools. The study will be done by administering an internet-based questionnaire to school employees at 50 elementary schools and conducting an environmental survey at 15 of these schools.

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Authorizing Statute(s): US Code: 42 USC Part 85a Name of Law: Occupatinal Safety and Health Investigations of Places of Employment
   PL: Pub.L. 91 - 596 20[a][1] Name of Law: Occupational Safety and Health
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 63207	10/23/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 63124	10/22/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
School Health Queationnaire	None	School Health Questionnaire
Non-Respondent Survey Questionnaire	None	Non-Respondent Survey Questionnaire

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ICR Summary 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	3,600	3,600	0	0	0	0
Annual Time Burden (Hours)	1,100	1,100	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $120,000

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]? No

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

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Common Form ICR:  No

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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: 03/02/2015

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