CDC Worksite Health Scorecard

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1014 CDC Worksite Health Scorecard	Form and Instruction	Modified	Available
Form 0920-1014 CDC Worksite Health Scorecard	Form and Instruction	Modified	Repair queued
Form 0920-1014 CDC Worksite Health Scorecard Registration	Form and Instruction	Modified	Available
Form 0920-1014 CDC Worksite Health Scorecard Registration	Form and Instruction	Modified	Repair queued
Attachment_E_CDC Worksite Health ScoreCard Non-Research Determination.pdf	Supplementary Document	Uploaded 2022-02-02	Repair queued
CDC_ScoreCard_0920-1014_privacy-narrative-signed.pdf	Supplementary Document	Uploaded 2022-02-02	Repair queued
Attachment_D_CDC Worksite Health ScoreCard FAQs.docx	Supplementary Document	Uploaded 2022-02-02	Repair queued
Attachment_C-4_CDC_ScoreCard_Resources for Action_updated_12-2021.pdf	Supplementary Document	Uploaded 2022-02-02	Repair queued
Attachment_C-3_CDC ScoreCard_Sample Benchmarking Report.pdf	Supplementary Document	Uploaded 2022-02-02	Repair queued
Attachment_B-1_60_Day_FRN_2021-20847.pdf	Supplementary Document	Uploaded 2022-02-02	Repair queued
Attachment_A-2_Funding Authority ACA PPHF.pdf	Supplementary Document	Uploaded 2022-02-02	Repair queued
Attachment_A-1_Authorizing Legislation.docx	Supplementary Document	Uploaded 2022-02-02	Repair queued
CDC Worksite Health ScoreCard SS_A_1-14-22_final.docx	Supporting Statement A	Uploaded 2022-02-04	Repair queued
CDC Worksite Health ScoreCard SS_B_1-4-22.docx	Supporting Statement B	Uploaded 2022-02-02	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
234914	CDC Worksite Health Scorecard	Form and Instruction	Modified	CDC Worksite Health Scorecard
234914	CDC Worksite Health Scorecard	Form and Instruction	Modified
234913	CDC Worksite Health Scorecard Registration	Form and Instruction	Modified	CDC Worksite Health Scorecard Registration
234913	CDC Worksite Health Scorecard Registration	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-1014	ICR Reference No: 202201-0920-013
Status: Historical Active	Previous ICR Reference No: 201901-0920-009
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1014
Title: CDC Worksite Health Scorecard
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/05/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/07/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2025	36 Months From Approved	03/31/2022
Responses	1,600	0	1,600
Time Burden (Hours)	1,067	0	667
Cost Burden (Dollars)	62,185	0	35,311

---

Abstract: CDC will continue to provide for the ongoing usage of an updated version of the CDC Worksite Health Scorecard, web-based organizational assessment, by the employer community. The resulting data will be used to support research and increase understanding of the organizational programs, policies, and practices that employers of various sizes and industry sectors have implemented to support health lifestyle behaviors. It will also document changes in organizational practices over time and allow CDC to provide better technical assistance to employers seeking guidance on building or maintaining workplace health promotion programs.

---

Authorizing Statute(s): US Code: 42 USC 2801 Name of Law: Public Health and Welfare
   PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 53315	09/27/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 6555	02/04/2022
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
CDC Worksite Health Scorecard	0920-1014	CDC Worksite Health Scorecard
CDC Worksite Health Scorecard Registration	0920-1014	CDC Worksite Health Scorecard Registration

---

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	1,600	1,600	0	0	0	0
Annual Time Burden (Hours)	1,067	667	0	400	0	0
Annual Cost Burden (Dollars)	62,185	35,311	0	26,874	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: The increase is due to correction of an admin error from the last package.

---

Annual Cost to Federal Government: $96,913

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]? Yes

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

---

Common Form ICR:  No

---

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: 02/07/2022

---