Information Collection

Local Effectiveness Assessment Project (LEAP), Part II

IC 221812 under ICR 201505-0920-007 · OMB 0920-1091.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1091 can be found here:

Documents and Forms

Document Name Document Type
Att 3a_KPI Guide Community Members.docx Other-WORD
Att 3b_KPI Guide Health Dept CBO.docx Other-WORD
Att 1_Recruitment Materials.docx Att 1_Recruitment Materials IC Document
Att 2_Informed Consent.docx Att 2_Consent Form IC Document
Att 4_Emory IRB Letter of Approval.pdf Att 4_Emory IRB Ltr of Approval IC Document
Att 4a - IRB Amendment Approval.pdf Att 4a_Emory IRB Amendment Approval IC Document
SSA.docx SupSta A IC Document
SSB.docx SupSta B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Local Effectiveness Assessment Project (LEAP), Part II	Agency IC Tracking Number:	16AQA

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att 3a_KPI Guide Community Members.docx		No		Fillable Printable
Other-WORD			Att 3b_KPI Guide Health Dept CBO.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 1_Recruitment Materials	Att 1_Recruitment Materials.docx	06/07/2016
Att 2_Consent Form	Att 2_Informed Consent.docx	06/07/2016
Att 4_Emory IRB Ltr of Approval	Att 4_Emory IRB Letter of Approval.pdf	06/07/2016
Att 4a_Emory IRB Amendment Approval	Att 4a - IRB Amendment Approval.pdf	06/07/2016
SupSta A	SSA.docx	06/08/2016
SupSta B	SSB.docx	06/08/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.