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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.