National Survey of Community Based Policy and Environmental Supports for Healthy Eating and Active Living

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-20QJ Critical Item Survey	Form and Instruction	New	Available
Form 0920-20QJ Critical Item Survey	Form and Instruction	New	Repair queued
Form 0920-20QJ Self-Administered Hardcopy Questionnaire	Form and Instruction	New	Available
Form 0920-20QJ Web Questionnaire Developer Logic	Form and Instruction	New	Available
Form 0920-20QJ Main Questionnaire	Form and Instruction	New	Repair queued
Attachment 12 -Privacy impact assessment form.pdf	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 11_ Human subjects document non-research determination.pdf	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 10_Privacy Narrative.pdf	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 7 - Telephone contacting scripts.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 6d_Last chance email.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 6c_SAQ cover letter.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 6b_Reminder email template.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 6a_Email invitation.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 5b - Frequently asked questions.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 5a_Survey invitation letter.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 4_Prenotification letter.docx	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 2a - 60-Day Federal Register Notice.pdf	Supplementary Document	Uploaded 2021-01-26	Repair queued
Attachment 1_Public Health Service Act [42 U.S.C. 241].pdf	Supplementary Document	Uploaded 2021-01-26	Repair queued
OMB Supporting Statement B.docx	Supporting Statement B	Uploaded 2021-01-26	Repair queued
OMB Supporting Statement A final.docx	Supporting Statement A	Uploaded 2021-01-26	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245435	Critical Item Survey	Form and Instruction	New	Critical Item Survey
245435	Critical Item Survey	Form and Instruction	New
245433	Main Questionnaire	Form and Instruction	New	Self-Administered Hardcopy Questionnaire
245433	Main Questionnaire	Form and Instruction	New	Web Questionnaire Developer Logic
245433	Main Questionnaire	Form and Instruction	New

ICR Details

OMB Control No: 0920-1327	ICR Reference No: 202101-0920-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-20QJ
Title: National Survey of Community Based Policy and Environmental Supports for Healthy Eating and Active Living
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 without change	Conclusion Date: 03/05/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/29/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	24 Months From Approved
Responses	7,067	0	0
Time Burden (Hours)	1,693	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This purpose of this proposed information collection is to measure progress municipal governments have made since 2014 in policies and practices to support healthy eating and physical activity for their residents in a nationally representative sample. Results will be used to examine policy and practice supports favorable for healthy diets and regular physical activity and progress since 2014, help identify the extent to which communities implement strategies consistent with current national recommendations, and guide CDC program activities and communities and researchers in local efforts to implement and evaluate policies and practices that support healthy behaviors.

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Authorizing Statute(s): 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:
	85 FR 43851	07/20/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 7391	01/28/2021
Did the Agency receive public comments on this ICR? Yes

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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
Critical Item Survey	0920-20QJ	Critical Item Survey
Main Questionnaire	0920-20QJ, 0920-20QJ	Web Questionnaire Developer Logic ,   Self-Administered Hardcopy Questionnaire

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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	7,067	0	0	7,067	0	0
Annual Time Burden (Hours)	1,693	0	0	1,693	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 Collection.

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Annual Cost to Federal Government: $653,288

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 01/29/2021

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