Information Collection Request

[NCCDPHP] Healthy Schools Program Evaluation

ICR 202504-0920-011 · OMB 0920-1455 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-24BJ Healthy Student Questionnaire Form Modified Available
Form 0920-24BJ Healthy Students Questionnaire Form Modified Available
Form 0920-24BJ Healthy Schools Questionnaire Form Unchanged Available
Form 0920-24BJ Healthy Schools Questionnaire Form Unchanged Repair queued
Form 0920-24BJ Interview Guide Priority LEA Form Modified Available
Form 0920-24BJ LEA Interviews Form Modified Repair queued
Form 0920-24BJ Interview Guide Recipient Form Modified Available
Form 0920-24BJ Recipient Interviews Form Modified Available
Form 0920-24BJ Monthly Reporting Form Form Modified Repair queued
Form 0920-24BJ Monthly Reporting Form Modified Available
Change Request Memo - DASH DP-23-0002 (Clean) 2025.05.02 V4.1.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-05-13 Available
Change Request Memo - DASH DP-23-0002 (Clean) 2025.05.02 V4.1.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-05-13 Repair queued
Attachment 12 - Screenshots of Healthy Student Questionnaire_updated w Race Ethnicity Q 10.31.24 (1) (002).docx Supplementary Document Uploaded 2025-01-04 Repair queued
Attachment 12 - Screenshots of Healthy Student Questionnaire_updated w Race Ethnicity Q 10.31.24 (1) (002).docx Supplementary Document Uploaded 2025-01-04 Repair queued
Attachment 11 - Healthy Student Questionnaire updated w Race Ethnicity Q 10.31.24.docx Supplementary Document Uploaded 2025-01-04 Available
Attachment 11 - Healthy Student Questionnaire updated w Race Ethnicity Q 10.31.24.docx Supplementary Document Uploaded 2025-01-04 Repair queued
FRN 30 Day Text - 2302 Healthy Schools Evaluation (003).docx Supplementary Document Uploaded 2024-08-22 Available
FRN 30 Day Text - 2302 Healthy Schools Evaluation (003).docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 20 - 2302 Healthy Schools IRB determination letter 06-05-24.pdf Supplementary Document Uploaded 2024-08-22 Available
Attachment 20 - 2302 Healthy Schools IRB determination letter 06-05-24.pdf Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 19 - Healthy Student Questionnaire Student Assent Form (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Available
Attachment 19 - Healthy Student Questionnaire Student Assent Form (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 18 - Healthy Student Questionnaire 18+ Consent Form (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 18 - Healthy Student Questionnaire 18+ Consent Form (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 16 - Healthy Schools Questionnaire Consent Form (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Available
Attachment 16 - Healthy Schools Questionnaire Consent Form (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 17 - Healthy Students Questionnaire Parent Consent Forms.docx Supplementary Document Uploaded 2024-08-22 Available
Attachment 17 - Healthy Students Questionnaire Parent Consent Forms.docx Supplementary Document Uploaded 2024-08-22 Available
Attachment 15 - Interview Consent Forms.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 15 - Interview Consent Forms.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 13 - Published 60 day FRN Healthy Schools.pdf Supplementary Document Uploaded 2024-08-22 Available
Attachment 13 - Published 60 day FRN Healthy Schools.pdf Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 10 - Screenshots of Healthy Schools Questionnaire (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Available
Attachment 10 - Screenshots of Healthy Schools Questionnaire (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 12 - Screenshots of Healthy Student Questionnaire (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 12 - Screenshots of Healthy Student Questionnaire (final) 6.14.24.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 08 - Interview Invitation Email.docx Supplementary Document Uploaded 2024-08-22 Available
Attachment 08 - Interview Invitation Email.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 05 - Monthly Indicator Report Qualtrics Screenshots (EO revised) 2025.05.02.docx Supplementary Document Uploaded 2025-05-13 Available
Attachment 05 - Monthly Indicator Report Qualtrics Screenshots (EO revised) 2025.05.02.docx Supplementary Document Uploaded 2025-05-13 Repair queued
Attachment 04 - Monthly Reporting Form Email Notification.docx Supplementary Document Uploaded 2024-08-22 Available
Attachment 04 - Monthly Reporting Form Email Notification.docx Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 02 - Authorizing Legislation - Evidence-Based Policymaking Act 2018.pdf Supplementary Document Uploaded 2024-08-22 Available
Attachment 02 - Authorizing Legislation - Evidence-Based Policymaking Act 2018.pdf Supplementary Document Uploaded 2024-08-22 Repair queued
Attachment 01 - Authorizing Legislation - Public Health Service Act.pdf Supplementary Document Uploaded 2024-08-22 Available
Attachment 01 - Authorizing Legislation - Public Health Service Act.pdf Supplementary Document Uploaded 2024-08-22 Repair queued
Healthy Schools - SSB.docx Supporting Statement B Uploaded 2024-08-22 Repair queued
Healthy Schools - SSB.docx Supporting Statement B Uploaded 2024-08-22 Repair queued
Healthy Schools - SSA (EO revised, clean) 2025.04.21.docx Supporting Statement A Uploaded 2025-05-13 Available
Healthy Schools - SSA (EO revised, clean) 2025.04.21.docx Supporting Statement A Uploaded 2025-05-13 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
270338 Healthy Students Questionnaire Form ModifiedHealthy Student Questionnaire
270338 Healthy Students Questionnaire Form Modified
270336 Healthy Schools Questionnaire Form UnchangedHealthy Schools Questionnaire
270336 Healthy Schools Questionnaire Form Unchanged
270335 LEA Interviews Form ModifiedInterview Guide Priority LEA
270335 LEA Interviews Form Modified
270334 Recipient Interviews Form ModifiedInterview Guide Recipient
270334 Recipient Interviews Form Modified
270318 Monthly Reporting Form ModifiedMonthly Reporting Form
270318 Monthly Reporting Form Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
01/31/2028 01/31/2028 01/31/2028
13,720 0 13,720
6,900 0 6,900
0 0 0





Reginfo record details
5
table that charts list of burden
IC Title Form No. Form Name
Healthy Schools Questionnaire 0920-24BJ
Healthy Students Questionnaire 0920-24BJ
LEA Interviews 0920-24BJ
Monthly Reporting 0920-24BJ
Recipient Interviews 0920-24BJ

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 13,720 13,720 0 0 0 0
Annual Time Burden (Hours) 6,900 6,900 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No