Workplace Health in America

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Workplace Health in America Survey - core and supplemental	Form and Instruction	New	Available
Screening and Recruiting Call	Form and Instruction	New	Available
Attachment H- WHA and Workplace Wellness Programs Crosswalk.docx	Supplementary Document	Uploaded 2016-09-26	Available
Attachment G- WHA Item Justification Table.docx	Supplementary Document	Uploaded 2016-09-26	Available
Attachment F_RTI_IRB exemption0214531.pdf	Supplementary Document	Uploaded 2016-02-17	Available
Attachment E_WHA Glossary_1-29-16.docx	Supplementary Document	Uploaded 2016-02-17	Available
Attachment D_WHA Frequently Asked Questions_1-29-16.docx	Supplementary Document	Uploaded 2016-02-17	Available
Attachment B_60-day FRN.pdf	Supplementary Document	Uploaded 2016-02-17	Available
Attachment A-3_PHSA Rsch_FINAL_1-3-14.pdf	Supplementary Document	Uploaded 2016-02-17	Available
Attachment A-2_Funding Authority ACA PPHF.pdf	Supplementary Document	Uploaded 2016-02-17	Available
Attachment A-1_Authorizing Legislation.docx	Supplementary Document	Uploaded 2016-02-17	Available
workplace wellness SS Part B_2_8_16 OMB comments_Clean_Copy_9-22-16.docx	Supporting Statement B	Uploaded 2016-09-26	Available
workplace wellness SS Part A_2_8_16 OMB Comments Clean_Copy_9-22-16.docx	Supporting Statement A	Uploaded 2016-09-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
220139	Workplace Health in America Survey - core and supplemental	Form and Instruction	New
220138	Screening and Recruiting Call	Form and Instruction	New

ICR Details

OMB Control No: 0920-1138	ICR Reference No: 201602-0920-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 16FG
Title: Workplace Health in America
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: 09/26/2016
	Date Received in OIRA: 02/25/2016
Terms of Clearance: Approval is granted for a one-time administration of this survey, consistent with the understanding that, before disseminating the results, CDC will conduct a thorough assessment of the potential for non-response bias to determine if the results can be characterized as nationally representative. Requests to OMB for future approval of subsequent iterations of this collection must be accompanied by an update on the response rates observed, and an assessment of the quality and utility of each of the questions for meeting the intended goals, with a focus on streamlining the survey instrument.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	24 Months From Approved
Responses	16,737	0	0
Time Burden (Hours)	3,974	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC plans to assess the extent to which employers in the U.S. are implementing health promotion programs and practices. CDC will survey a nationally representative, random sample of work sites stratified by work site size, HHS region, and industry group. Hospitals will be included as a separate stratum.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1 Name of Law: Patient Protection and ACA
   US Code: 42 USC 280 Name of Law: PHSA Employer-based Wellness Program
   US Code: 42 USC 241 Name of Law: PHSA
  

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 74110	11/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 9474	02/25/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Screening and Recruiting Call	none	Screening and Recruiting Call
Workplace Health in America Survey - core and supplemental	none, none, none, none, none	Workplace Health in America Survey ,   Workplace Health in America -screenshots section 1 ,   Workplace Health in America - screenshots section 2 ,   Workplace Health in America - screenshots section 3 ,   Workplace Health in America - screenshots section 4

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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	16,737	0	0	16,737	0	0
Annual Time Burden (Hours)	3,974	0	0	3,974	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: $1,004,300

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]? 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: 02/25/2016

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