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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.