Employer Perspectives of an Insurer-Sponsored Wellness Grant

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Wellness Grant_SSA clean.docx	Supporting Statement A	Uploaded 2016-06-14	Available
Section B WWGP 20160104.docx	Supporting Statement B	Uploaded 2016-01-07	Available
Attachment M Employer Participation Information sheet 20140610.docx	Supplementary Document	Uploaded 2016-01-06	Available
Attachment L Information Security Plan 20151210.docx	Supplementary Document	Uploaded 2016-01-06	Available
Attachment I IRB Renewal 01379_01251_01370_ HSRB 14-DSHEFS-01XP 2015.pdf	Supplementary Document	Uploaded 2016-01-06	Available
Attachment H Letter of support from OHBWC.docx	Supplementary Document	Uploaded 2016-01-06	Available
Attachment G NORA FY14 Intramural Funding Opportunity Announcements (JHoward).pdf	Supplementary Document	Uploaded 2016-01-06	Available
Attachment F OHBWC WWGP Overview and Forms.pdf	Supplementary Document	Uploaded 2016-01-06	Available
Attachment E - full research project description.docx	Supplementary Document	Uploaded 2016-01-06	Available
Attachment D OBWC- NIOSH Letter of Agreement 5_04_12.docx	Supplementary Document	Uploaded 2016-01-06	Available
Attachment C2 CDC-2014-0014-0005 - TWH agenda presentation & Fed Notice.pdf	Supplementary Document	Uploaded 2016-01-06	Available
Attachment C1 NIOSH Strategic Goals for WWGP proj.docx	Supplementary Document	Uploaded 2016-01-06	Available
Attachment B 2015-10286 - 60-day Federal Register for WWGP.pdf	Supplementary Document	Uploaded 2016-01-06	Available
Attachment A Authorizing Legislation (2).docx	Supplementary Document	Uploaded 2016-01-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219521	Case Study Verification Interview	Instruction	New
219520	Employer Interview for Occupational Health and Safety Specialists	Instruction	New
219519	Employer Interview for Wellness Program Coordinators	Instruction	New

ICR Details

OMB Control No: 0920-1117	ICR Reference No: 201601-0920-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15ADW
Title: Employer Perspectives of an Insurer-Sponsored Wellness Grant
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: 06/14/2016
	Date Received in OIRA: 01/14/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	12 Months From Approved
Responses	150	0	0
Time Burden (Hours)	150	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This ICR is to determine the effectiveness and economic return of grant-supported workplace wellness programs and to understand the impact of integrating of wellness with traditional occupational safety and health programs, including economic analyses to determine costs, savings, and benefits to cost ratios. The collection involves semi-structured in-person interviews and brief phone interviews.

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Authorizing Statute(s): US Code: 29 USC 669 Name of Law: Occupational Safety and Health 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 25296	05/04/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 1424	01/12/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Employer Interview for Occupational Health and Safety Specialists
Employer Interview for Wellness Program Coordinators
Case Study Verification Interview	none	Annual Case Study

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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	150	0	0	150	0	0
Annual Time Burden (Hours)	150	0	0	150	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 ICR.

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Annual Cost to Federal Government: $20,117

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

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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: 01/14/2016

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