National Healthy Worksite Program

OMB Control No: 0920-0965	ICR Reference No: 201206-0920-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Healthy Worksite Program
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 11/21/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/13/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is establishing a new, comprehensive workplace health program, the National Healthy Worksite Program (NHWP). The purpose of the program is to imporve the health of workers and their families. CDC will work with employers to implement and evaluate workplace-based programs that address physical activity, nutrition, and tobacco use.

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Authorizing Statute(s): None

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:
	77 FR 8874	02/15/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 34951	06/12/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 22

IC Title Form No. Form Name Employer Phone Interview Guide Organizational Assessment (Employer) Employee Eligiblity File Format Requirements Employer Information Form Health Screening Site Interview Form Employer Discussion Guide: Steering Committee Members (Case Studies) Employer Discussion Guide: Wellness Committee (Case Studies) Employer Follow-Up Survey Worksite Health 101 Training Survey: Part I-III Worksite Health 101 Training Survey: Part IV Community Participant Emgagement Feedback Survey All Employee Survey Success Story Consent Form Satisfaction Survey (Employee) Wellness Challenge Logs (Employee) - Feel Fit with Fiber Wellness Challenge Logs (Employee) - Lower Your Weight by Eight Wellness Challenge Logs (Employee) - Maintain Don't Gain Wellness Challenge Logs (Employee) - Mix It Up Wellness Challenge Logs (Employee) - Quench Your Thirst Wellness Challenge Logs (Employee) - Step into Health Wellness Challenge Logs (Employee) - Nutrition & Physical Activity / Lifestyle Tracker Health Screening Consent / Contact Form

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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 information collect request supporting a new programmatic initiative. Information will be collected for program evaluation.

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Annual Cost to Federal Government: $1,017,108

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

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? Uncollected

Agency Contact: Thelma Sims 4046394771

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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: 06/13/2012

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