Information Collection

Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP)

IC 231069 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP) Form and Instruction
Pre-Session Survey Att 1. Pre-Session Form Revised 3-6-2018.docx Form and Instruction
Post-Session Survey Att 2. Post-Session Form 3-6-2018.docx Form and Instruction
Enrollment Materials and Referral Tracking Form Att 3. Enrollment Materials and Referral Tracking Form 3-6-2018.docx Form and Instruction
LCP Staff/Coach Interview Guide Att 4. LCP Staff Interview Guide 3-6-2018.docx Form and Instruction
Att 6. LCP Staff Interview Informed Consent 3-6-2018.docx LCP Staff Informed Consent IC Document
Att 7. study approval2016(full).pdf IRB Approval - Abt Associates IC Document
Att 5. Observation Tool_3-6-18.docx Observation Tool IC Document
Supporting Statement A_ (EASE) 20APR2018 Final.docx Supporting Statement A IC Document
Supporting Statement B_ (EASE) 20APR2018 Final.docx Supporting Statement B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP)	Agency IC Tracking Number:	0920-1154-18ABE

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form and Instruction	NA	Pre-Session Survey	Att 1. Pre-Session Form Revised 3-6-2018.docx	NA	No	Paper Only
Form and Instruction	NA	Post-Session Survey	Att 2. Post-Session Form 3-6-2018.docx	NA	No	Paper Only
Form and Instruction	NA	Enrollment Materials and Referral Tracking Form	Att 3. Enrollment Materials and Referral Tracking Form 3-6-2018.docx	NA	No	Paper Only
Form and Instruction	NA	LCP Staff/Coach Interview Guide	Att 4. LCP Staff Interview Guide 3-6-2018.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 768	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	768	768
Annual IC Time Burden (Hours)	168	168
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
LCP Staff Informed Consent	Att 6. LCP Staff Interview Informed Consent 3-6-2018.docx	04/23/2018
IRB Approval - Abt Associates	Att 7. study approval2016(full).pdf	04/23/2018
Observation Tool	Att 5. Observation Tool_3-6-18.docx	04/23/2018
Supporting Statement A	Supporting Statement A_ (EASE) 20APR2018 Final.docx	04/23/2018
Supporting Statement B	Supporting Statement B_ (EASE) 20APR2018 Final.docx	04/23/2018

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