CDC Work@Health Advance Program: Evaluation of Train-the-Trainer and Advanced Technical Assistance Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Work@Health Advance SS B_073015.doc	Supporting Statement B	Uploaded 2015-08-03	Available
Work@Health Advance SS A_073015.doc	Supporting Statement A	Uploaded 2015-08-03	Available
Att D_Information Collection Flowchart_4-20-15.docx	Supplementary Document	Uploaded 2015-06-04	Available
Att C_Program Objective - Survey Instrument Crosswalk_4-20-15.doc	Supplementary Document	Uploaded 2015-06-04	Available
Att B-2_Summary of Public Comments_4-3-15.docx	Supplementary Document	Uploaded 2015-06-04	Available
Att B-1_0920-15OO 60-day FRN 2 18 2015.pdf	Supplementary Document	Uploaded 2015-06-04	Available
Att A-3_PHSA Rsch_FINAL_1-3-14.pdf	Supplementary Document	Uploaded 2015-06-04	Available
Att A-2_Funding Authority_ACA-FINAL_1-3-14.pdf	Supplementary Document	Uploaded 2015-06-04	Available
Att A-1_Authorizing Legislation_EBWP_FINAL_1-3-14.docx	Supplementary Document	Uploaded 2015-06-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216868	Att J_Train-the-Trainer Knowledge and Skills Survey	Other-WORD Screenshots	New
216867	Att I_Train-the-Trainer Application Form	Other-WORD Screenshots	New
216866	Att H_Employer Follow-up Survey	Other-WORD Screenshots	New
216865	Att G_Follow-up Accreditation Survey	Other-WORD Screenshots	New
216864	Att F_Advance Evaluataion	Other-WORD Screenshots	New
216862	Att E_Accrediation Readiness Assessment Tool	Other-WORD/Screenshots	New

ICR Details

OMB Control No: 0920-1077	ICR Reference No: 201506-0920-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15OO
Title: CDC Work@Health Advance Program: Evaluation of Train-the-Trainer and Advanced Technical Assistance Program
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/03/2015
	Date Received in OIRA: 06/11/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	36 Months From Approved
Responses	1,120	0	0
Time Burden (Hours)	450	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC established the Work@Health program to raise employer knowledge and skills related to workplace health programs. The Advance Program builds on previous efforts. Over 3 years, 360 employers will receive advanced technical assistance to help prepare for accreditation of their workplace health programs. In addition, 300 individuals will participate in a train-the-trainer experience to promote program dissemination. Information will be collected from participants for program implementation and improvement.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 4002 Name of Law: Prevention and Public Health Fund
  

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 8657	02/18/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 31376	06/02/2015
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Att E_Accrediation Readiness Assessment Tool
Att F_Advance Evaluataion
Att G_Follow-up Accreditation Survey
Att H_Employer Follow-up Survey
Att I_Train-the-Trainer Application Form
Att J_Train-the-Trainer Knowledge and Skills Survey

---

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	1,120	0	0	1,120	0	0
Annual Time Burden (Hours)	450	0	0	450	0	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: This is a New collection request for a new OMB Control Number

---

Annual Cost to Federal Government: $1,234,300

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? 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: 06/11/2015

---