CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Trainee Technical Assistance Survey	Form	Modified	Available
Train-the-Trainer Technical Assistance Survey	Form	Modified	Available
Instructor/Coach Group Discussion Guide	Form and Instruction	Modified	Available
Wave 2 Trainee Reaction Survey	Form	Modified	Available
Train-the-Trainer Reaction Survey	Form	Modified	Available
Train-the-Trainer Participant Survey	Form	Modified	Available
Train-the-Trainer Application Form	Form	Modified	Available
Trainee Focus Group Discussion Guide	Form and Instruction	Modified	Available
Case Study Interviews with Selected Trainees	Form and Instruction	Modified	Available
Trainee Reaction Survey Blended Model	Form	Modified	Available
Trainee Reaction Survey - Online Model	Form	Modified	Available
Trainee Reaction Survey- Hands-On Model	Form	Modified	Available
Trainee KAB Survey	Form	Modified	Available
Case Study Interviews with Employees	Form and Instruction	Modified	Available
Case Study Interviews with Senior Leadership	Form and Instruction	Modified	Available
Employer Follow-up Survey	Form	Modified	Available
Organizational Assessment	Form	Modified	Available
CDC Worksite Health Scorecard	Form	Modified	Available
Employer Application Form	Form	Modified	Available
Work@Health Extension SS_B 12-18-15.doc	Supporting Statement B	Uploaded 2016-01-06	Available
Work@Health SS_A 01062016.doc	Supporting Statement A	Uploaded 2016-01-06	Available
Att J_Employer Training_FAQ.doc	Supplementary Document	Uploaded 2015-12-21	Available
Att D_Data Collection Flowchart_12-14-15.doc	Supplementary Document	Uploaded 2015-12-21	Available
Att C_Objective-Survey Instrument Crosswalk.doc	Supplementary Document	Uploaded 2015-12-21	Available
Att B-2_Summary of Public Comments.docx	Supplementary Document	Uploaded 2015-12-21	Available
Att B-1_60-day FRN 8 04 2015.pdf	Supplementary Document	Uploaded 2015-12-21	Available
A-3_PHSA Rsch.pdf	Supplementary Document	Uploaded 2015-12-21	Available
A-2_Funding Authority_ACA.pdf	Supplementary Document	Uploaded 2015-12-21	Available
A-1_Authorizing Legislation_EBWP.docx	Supplementary Document	Uploaded 2015-12-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213479	Trainee Technical Assistance Survey	Form	Modified
213472	Train-the-Trainer Technical Assistance Survey	Form	Modified
209594	Instructor/Coach Group Discussion Guide	Form and Instruction	Modified
209593	Wave 2 Trainee Reaction Survey	Form	Modified
209591	Train-the-Trainer Reaction Survey	Form	Modified
209590	Train-the-Trainer Participant Survey	Form	Modified
209589	Train-the-Trainer Application Form	Form	Modified
209588	Trainee Focus Group Discussion Guide	Form and Instruction	Modified
209587	Case Study Interviews with Selected Trainees	Form and Instruction	Modified
209585	Trainee Reaction Survey Blended Model	Form	Modified
209584	Trainee Reaction Survey - Online Model	Form	Modified
209583	Trainee Reaction Survey- Hands-On Model	Form	Modified
209582	Trainee KAB Survey	Form	Modified
209581	Case Study Interviews with Employees	Form and Instruction	Modified
209580	Case Study Interviews with Senior Leadership	Form and Instruction	Modified
209579	Employer Follow-up Survey	Form	Modified
209578	Organizational Assessment	Form	Modified
209577	CDC Worksite Health Scorecard	Form	Modified
209576	Employer Application Form	Form	Modified

ICR Details

OMB Control No: 0920-1006	ICR Reference No: 201512-0920-008
Status: Historical Active	Previous ICR Reference No: 201410-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 21040
Title: CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/30/2016
	Date Received in OIRA: 01/11/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	3,310	0	5,036
Time Burden (Hours)	1,044	0	1,603
Cost Burden (Dollars)	0	0	0

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Abstract: Through the Work@Health Program, CDC provides training and technical assistance to employers to strengthen science-based worksite health programs and employee engagement in these programs. Information is collected for program administration and evaluation.

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Authorizing Statute(s): US Code: 42 USC 2801 Name of Law: Employer-based Wellness Program
   PL: Pub.L. 111 - 148 1001 Name of Law: Affordable Care Act
   US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 46282	08/04/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 79591	12/22/2015
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 19

table that charts list of burden

IC Title	Form No.	Form Name
Trainee Technical Assistance Survey	none	Trainee Technical Assistance Survey
Trainee Reaction Survey- Hands-On Model	none	Trainee Reaction Survey
Trainee Reaction Survey - Online Model	none	Trainee Reaction Survey
Trainee Reaction Survey Blended Model	none	Trainee Reaction Survey
Train-the-Trainer Participant Survey	none	Train the Trainer Participant Survey
Train-the-Trainer Reaction Survey	none	Train the Trainer Reaction Survey
Wave 2 Trainee Reaction Survey	none	Trainer Reaction Survey
Instructor/Coach Group Discussion Guide	none	Instructor Discussion Guide
Employer Application Form	none	Employer Application
CDC Worksite Health Scorecard	none	Worksite Health Scorecard
Organizational Assessment	none	Organizational Assessment
Employer Follow-up Survey	none	Employer Follow-up Survey
Case Study Interviews with Senior Leadership	none	Case Study Interviews Guide with Leadership
Case Study Interviews with Employees	none	Case Study Interview Guide with Employees
Trainee KAB Survey	none	Trainee KAB Survey
Train-the-Trainer Technical Assistance Survey	none	Train the Trainee Technical Assisstance Survey
Case Study Interviews with Selected Trainees	none	Case Study Interview Guide with Trainees
Trainee Focus Group Discussion Guide	none	Trainee Focus Group Guide
Train-the-Trainer Application Form	none	Train the Trainer Application

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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	3,310	5,036	0	-1,726	0	0
Annual Time Burden (Hours)	1,044	1,603	0	-559	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden reduction is primarily due to annualizing the burden over three years, instead of two. There are additional reductions due to reducing the number of respondents for two ICs.

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Annual Cost to Federal Government: $2,709,724

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? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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

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Common Form ICR:  No

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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: 01/11/2016

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