National Healthy Worksite Program

OMB Control No: 0920-0965	ICR Reference No: 201303-0920-012
Status: Historical Active	Previous ICR Reference No: 201206-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No: 19147
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: Approved with change	Conclusion Date: 05/13/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/26/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	36 Months From Approved
Responses	54,878	0	0
Time Burden (Hours)	17,747	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): PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act    US Code: 42 USC 301 Name of Law: Public Health Service Act

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 39451	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: 23

IC Title Form No. Form Name All Employee Survey 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 Employee Health Assessment Employee Success Story Consent Form Employee Satisfaction Survey Lower Your Weight by Eight Challenge Log Nutrition and Physical Activity Tracker Log / Health Tracker Health Screening Consent / Contact Form Step into Health Challenge Log Maintain Don't Gain Challenge Log Mix It Up Challenge Log Quench Your Thirst Challenge Log Feel Fit with Fiber Challenge Log

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ICR Summary 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	54,878	0	0	54,878	0	0
Annual Time Burden (Hours)	17,747	0	0	17,747	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 information collection request supporting a new programmatic initiative. Information will be collected for program evaluation. The ICR has been revised in response to comments from OMB, HHS and DPC.

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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: 03/26/2013

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