Baseline Let's Move! Cities, Towns and Counties Participant Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0990-0388 Part B.docx	Supporting Statement B	Uploaded 2015-06-17	Available
0990-Let's Move! Cities Towns and Countries MEMO.pdf	Supplementary Document	Uploaded 2012-01-05	Available
0990-0388Lets Move Cities Towns and Counties_OMB package_5-10-2015.docx	Supporting Statement A	Uploaded 2015-06-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217054	Blank Medal Status Survey LMCTC	Other-	New
200706	Government Official (city, town, county)	Other-Survey	Removed

ICR Details

OMB Control No: 0990-0388	ICR Reference No: 201502-0990-013
Status: Historical Active	Previous ICR Reference No: 201206-0990-001
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Baseline Let's Move! Cities, Towns and Counties Participant Survey
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/15/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/23/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved	12/31/2015
Responses	500	0	1,000
Time Burden (Hours)	250	0	250
Cost Burden (Dollars)	0	0	0

---

Abstract: The survey requests information about the activities the locality is choosing to undertake. The responses to these questions will be used to show progress and successes over time for localities participating in Let's Move! Cities, Towns, and Counties, as well as how HHS can adjust its technical assistance in response to localities'progress. This initiative was launched preliminarily in the spring of 2010, and is being re-launched in January of 2011.

---

Authorizing Statute(s): PL: Pub.L. 42 - 241 301 Name of Law: U.S. Public Health Service Act
  

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:
	80 FR 11675	03/04/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 35655	06/22/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Blank Medal Status Survey LMCTC
Government Official (city, town, county)

---

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	500	1,000	0	500	-1,000	0
Annual Time Burden (Hours)	250	250	0	250	-250	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: No

Burden Reduction Due to:

Short Statement: Since the initial OMB approval for this request in 2012, there has been a change to the estimated number of survey respondents (reduced from 1000 to 500) and to the time taken to complete the survey (increased from 15 minutes to 30 minutes), but not to the overall burden hours, which remains the same at 250 hours.

---

Annual Cost to Federal Government: $25,417

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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

---

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: 06/23/2015

---