Information Collection

Pretests for an alternate data collection method (ADCM) for FoodAPS2

IC 221075 under ICR 201511-0536-001 · OMB 0536-0073.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0536-0073 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pretest_generic_clearance_Appendix B_Recruitment Script.docx	Other-Screening questions
Pretest_generic_clearance_Appendix C-1_Web-based FARS Screenshots.docx	Other-Web-based Food reporting syste
Pretest_generic_clearance_Appendix C-2_Income Worksheet.docx	Other-Income Worksheet web instrumen
Pretest_generic_clearance_Appendix C-3_Meals and Snacks Form.docx	Other-Meal and Snake Form
Pretest_generic_clearance_Appendix C-4_Final Interview Income Questions.docx	Other-Final Interview Income Questio
Pretest_generic_clearance_Appendix C-5_Screener_Pretest 2_04112016_final.docx	Other-Screener for Pretest 2
Pretest_generic_clearance_Appendix C-6_Initial Interview_Pretest 2.docx	Other-Initial Interview_Pretest 2
Pretest_generic_clearance_Appendix C-7_Final Interview_Pretest 2_04122016_final.docx	Other-Final Interview_Pretest 2
Pretest_generic_clearance_Appendix A_Recruitment Ad.docx Appendix A_Recruitment Ad	IC Document
Pretest_generic_clearance_Appendix D-2-Minor Assent for Pretest 1&2_04122016_final.docx Appendix D-2-Minor Assent for Pretest 1&2	IC Document
Pretest_generic_clearance_Appendix E-Pretest 1 Debriefing Protocol.docx Appendix E-Pretest 1 Debriefing Protocol	IC Document
Pretest_generic_clearance_Appendix F-Feedback Form_Pretest 2.docx Appendix F-Feedback Form_Pretest 2	IC Document
Pretest_generic_clearance_Appendix H_Study Fact Sheet.docx Appendix H_Study Fact Sheet	IC Document
Pretest_generic_clearance 04222016-Rev.docx Study Requesting Memo	IC Document
Pretest_generic_clearance_Appendix D-1-Consent Form_Pretest 1 _04222016_rev.docx Appendix D-1-Consent Form_Pretest 1	IC Document
Pretest_generic_clearance_Appendix D-3-Consent Form_Pretest 2_04222016_rev.docx Appendix D-3-Consent Form_Pretest 2	IC Document
Pretest_generic_clearance_Appendix G-1_Disclaimer for Pretest 1_PW.docx Appendix G-1_Disclaimer for Pretest 1	IC Document
Pretest_generic_clearance_Appendix G-2_Disclaimer_Pretest 2_PW.docx Appendix G-2_Disclaimer_Pretest 2	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Pretests for an alternate data collection method (ADCM) for FoodAPS2

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screening questions	Pretest_generic_clearance_Appendix B_Recruitment Script.docx	Yes	Yes	Fillable Printable
Other-Web-based Food reporting system	Pretest_generic_clearance_Appendix C-1_Web-based FARS Screenshots.docx	Yes	Yes	Fillable Fileable
Other-Income Worksheet web instrument	Pretest_generic_clearance_Appendix C-2_Income Worksheet.docx	Yes	Yes	Fillable Fileable
Other-Meal and Snake Form	Pretest_generic_clearance_Appendix C-3_Meals and Snacks Form.docx	Yes	Yes	Fillable Fileable
Other-Final Interview Income Questions	Pretest_generic_clearance_Appendix C-4_Final Interview Income Questions.docx	Yes	Yes	Fillable Fileable
Other-Screener for Pretest 2	Pretest_generic_clearance_Appendix C-5_Screener_Pretest 2_04112016_final.docx	Yes	Yes	Fillable Fileable
Other-Initial Interview_Pretest 2	Pretest_generic_clearance_Appendix C-6_Initial Interview_Pretest 2.docx	Yes	Yes	Fillable Fileable
Other-Final Interview_Pretest 2	Pretest_generic_clearance_Appendix C-7_Final Interview_Pretest 2_04122016_final.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	263	263
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix A_Recruitment Ad	Pretest_generic_clearance_Appendix A_Recruitment Ad.docx	04/14/2016
Appendix D-2-Minor Assent for Pretest 1&2	Pretest_generic_clearance_Appendix D-2-Minor Assent for Pretest 1&2_04122016_final.docx	04/14/2016
Appendix E-Pretest 1 Debriefing Protocol	Pretest_generic_clearance_Appendix E-Pretest 1 Debriefing Protocol.docx	04/14/2016
Appendix F-Feedback Form_Pretest 2	Pretest_generic_clearance_Appendix F-Feedback Form_Pretest 2.docx	04/14/2016
Appendix H_Study Fact Sheet	Pretest_generic_clearance_Appendix H_Study Fact Sheet.docx	04/14/2016
Study Requesting Memo	Pretest_generic_clearance 04222016-Rev.docx	04/25/2016
Appendix D-1-Consent Form_Pretest 1	Pretest_generic_clearance_Appendix D-1-Consent Form_Pretest 1 _04222016_rev.docx	04/25/2016
Appendix D-3-Consent Form_Pretest 2	Pretest_generic_clearance_Appendix D-3-Consent Form_Pretest 2_04222016_rev.docx	04/25/2016
Appendix G-1_Disclaimer for Pretest 1	Pretest_generic_clearance_Appendix G-1_Disclaimer for Pretest 1_PW.docx	04/25/2016
Appendix G-2_Disclaimer_Pretest 2	Pretest_generic_clearance_Appendix G-2_Disclaimer_Pretest 2_PW.docx	04/25/2016

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