Information Collection

National Food Study Pilot

IC 223174 under ICR 201608-0536-001 · OMB 0536-0074.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
B1a Household Screener_Spanish.docx	Other-Household Screener_Spanish Ver
B2 Initial Interview.docx	Other-Initial Interview_English vers
B2a Initial Interview_Spanish .docx	Other-Initial Interview_Spanish vers
B3 Food Log.docx	Other-Food Log_English Version
B3a Food Log_Spanish.docx	Other-Food Log_Spanish Version
B4 Income Worksheet.docx	Other-Income Worksheet_English Versi
B4a Income Worksheet_Spanish.docx	Other-Income Worksheet_Spanish Versi
B5 Meals and Snacks Form.docx	Other-Meals and Snacks Form_English
B5a Meals and Snacks Form_Spanish.docx	Other-Meals and Snacks Form_Spanish
B6 Nonresponse Followup.docx	Other-Nonresponse Followup_English V
B6a Nonresponse Followup_Spanish.docx	Other-Nonresponse Followup_Spanish V
B7 Final Interview.docx	Other-Final Interview _English Versi
B7a Final Interview_Spanish.docx	Other-Final Interview _Spanish Versi
B8 Respondent Feedback.docx	Other-Respondent Feedback_English Ve
B8a Respondent Feedback_Spanish.docx	Other-Respondent Feedback_Spanish Ve
B9 Recall Interview.docx	Other-Recall Interview_English Versi
B1 Household Screener.docx	Other-Household Screener_English Ver
A6 Westat Confidentiality and Nondisclousure Agreement.pdf A6 Westat Confidentiality and Nondisclousure Agreement	IC Document
A7 Westat IRB Approval.docx A7 Westat IRB Approval	IC Document
A8a 60 Day FRN.pdf A8a 60 Day FRN	IC Document
A9 Pretest Report.pdf A9 Pretest Report	IC Document
Response to NASS Comments 081116.docx ERS Response to NASS Comments	IC Document
A1 Advance letter.docx A1 Advance letter_English Version	IC Document
A1a Advance letter_Spanish.doc A1a Advance letter_Spanish Version	IC Document
A2 Information Sheet _English_09212016.doc A2 Information Sheet_English Version	IC Document
A2a Information Sheet _Spanish.doc A2a Information Sheet_Spanish Version	IC Document
A5a Parental Consent Form.docx A5a Parental Consent Form_English Version	IC Document
A5b Individual Assent-Consent Form.docx A5b Individual Assent-Consent Form_English Version	IC Document
A5ba Individual Assent-Consent Form_Spanish.doc A5ba Individual Assent-Consent Form_Spanish Version	IC Document
A3 Disclaimer.docx A3 Disclaimer	IC Document
A3a Disclaimer_Spanish.doc A3a Disclaimer_Spanish	IC Document
A4 Consent Form.docx A4 Consent Form_English Version	IC Document
A4a Consent Form_Spanish.doc A4a Consent Form_Spanish Version	IC Document
A5a Parental Consent Form.docx A5a Parental Consent Form_English Version	IC Document
A5aa Parental Consent Form_Spanish.doc A5aa Parental Consent Form_Spanish	IC Document
ERS respose to omb passback.docx ERS respose to omb passback	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

National Food Study Pilot

Agency IC Tracking Number:

Is this a Common Form? No

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-Household Screener_Spanish Version	B1a Household Screener_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Initial Interview_English version	B2 Initial Interview.docx	Yes	Yes	Fillable Fileable
Other-Initial Interview_Spanish version	B2a Initial Interview_Spanish .docx	Yes	Yes	Fillable Fileable
Other-Food Log_English Version	B3 Food Log.docx	Yes	Yes	Fillable Fileable
Other-Food Log_Spanish Version	B3a Food Log_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Income Worksheet_English Version	B4 Income Worksheet.docx	Yes	Yes	Fillable Fileable
Other-Income Worksheet_Spanish Version	B4a Income Worksheet_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Meals and Snacks Form_English Version	B5 Meals and Snacks Form.docx	Yes	Yes	Fillable Fileable
Other-Meals and Snacks Form_Spanish Version	B5a Meals and Snacks Form_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Nonresponse Followup_English Version	B6 Nonresponse Followup.docx	Yes	Yes	Fillable Fileable
Other-Nonresponse Followup_Spanish Version	B6a Nonresponse Followup_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Final Interview _English Version	B7 Final Interview.docx	Yes	Yes	Fillable Fileable
Other-Final Interview _Spanish Version	B7a Final Interview_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Respondent Feedback_English Version	B8 Respondent Feedback.docx	Yes	Yes	Fillable Fileable
Other-Respondent Feedback_Spanish Version	B8a Respondent Feedback_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Recall Interview_English Version	B9 Recall Interview.docx	Yes	Yes	Fillable Fileable
Other-Household Screener_English Version	B1 Household Screener.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500

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	2,500	2,500
Annual IC Time Burden (Hours)	6,575	6,575
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
A6 Westat Confidentiality and Nondisclousure Agreement	A6 Westat Confidentiality and Nondisclousure Agreement.pdf	08/24/2016
A7 Westat IRB Approval	A7 Westat IRB Approval.docx	08/24/2016
A8a 60 Day FRN	A8a 60 Day FRN.pdf	08/24/2016
A9 Pretest Report	A9 Pretest Report.pdf	09/21/2016
ERS Response to NASS Comments	Response to NASS Comments 081116.docx	08/24/2016
A1 Advance letter_English Version	A1 Advance letter.docx	09/21/2016
A1a Advance letter_Spanish Version	A1a Advance letter_Spanish.doc	09/21/2016
A2 Information Sheet_English Version	A2 Information Sheet _English_09212016.doc	09/21/2016
A2a Information Sheet_Spanish Version	A2a Information Sheet _Spanish.doc	09/21/2016
A5a Parental Consent Form_English Version	A5a Parental Consent Form.docx	09/21/2016
A5b Individual Assent-Consent Form_English Version	A5b Individual Assent-Consent Form.docx	09/21/2016
A5ba Individual Assent-Consent Form_Spanish Version	A5ba Individual Assent-Consent Form_Spanish.doc	09/21/2016
A3 Disclaimer	A3 Disclaimer.docx	12/06/2016
A3a Disclaimer_Spanish	A3a Disclaimer_Spanish.doc	12/06/2016
A4 Consent Form_English Version	A4 Consent Form.docx	12/06/2016
A4a Consent Form_Spanish Version	A4a Consent Form_Spanish.doc	12/06/2016
A5a Parental Consent Form_English Version	A5a Parental Consent Form.docx	12/06/2016
A5aa Parental Consent Form_Spanish	A5aa Parental Consent Form_Spanish.doc	12/06/2016
ERS respose to omb passback	ERS respose to omb passback.docx	12/06/2016

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