Main Questionnaire

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

Documents and Forms

Document Name Document Type
Form 0920-20QJ Main Questionnaire Form and Instruction
0920-20QJ Web Questionnaire Developer Logic Attachment 3a - Web questionnaire specifications.docx Form and Instruction
0920-20QJ Web Questionnaire Developer Logic Attachment 3a - Web questionnaire specifications.docx Form and Instruction
0920-20QJ Self-Administered Hardcopy Questionnaire Attachment 3b_Self administered hardcopy questionnaire.pdf Form and Instruction
0920-20QJ Self-Administered Hardcopy Questionnaire Attachment 3b_Self administered hardcopy questionnaire.pdf Form and Instruction
Attachment 9_Web questionnaire screenshots.pdf Main Questionnaire Screenshots IC Document
Attachment 9_Web questionnaire screenshots.pdf Main Questionnaire Screenshots IC Document

Information Collection (IC) Details

IC Title:	Main Questionnaire	Agency IC Tracking Number:	0920-20QJ

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-20QJ	Web Questionnaire Developer Logic	Attachment 3a - Web questionnaire specifications.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QJ	Self-Administered Hardcopy Questionnaire	Attachment 3b_Self administered hardcopy questionnaire.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,650	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,650	2,650
Annual IC Time Burden (Hours)	1,325	1,325
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Main Questionnaire Screenshots	Attachment 9_Web questionnaire screenshots.pdf	01/26/2021

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