OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation

ICR 201410-0920-013 · OMB 0920-1006 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
CDC Work@Health Trainee Technical Assistance Survey Form and Instruction New Available
CDC Work@Health Train-the-Trainer Technical Assistance Survey Form and Instruction New Available
Rev 0920-1006 Change Request_10-10-14.docx Justification for No Material/Nonsubstantive Change Uploaded 2014-10-14 Repair queued
Revised Burden Table_tracked changes_10-9-14.docx Supplementary Document Uploaded 2014-10-13 Repair queued
Work@Health Phase 2 SS_B.doc Supporting Statement B Uploaded 2013-12-02 Repair queued
PHMC IRB Determination.pdf Supplementary Document Uploaded 2013-12-02 Available
Att J_Work@Health Employer Training_FAQ.doc Supplementary Document Uploaded 2013-12-02 Repair queued
Att D_Work@Health Data Collection Flowchart.doc Supplementary Document Uploaded 2013-12-02 Repair queued
Att C_Program Objective - Survey Instrument Crosswalk.doc Supplementary Document Uploaded 2013-12-02 Available
Att B2_Summary of Public Comments.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att A3_PHSA Rsch.pdf Supplementary Document Uploaded 2013-12-02 Available
Att B1_Federal Register Notice.pdf Supplementary Document Uploaded 2013-12-02 Repair queued
Att A2_Funding Authority_ACA.pdf Supplementary Document Uploaded 2013-12-02 Available
Att A1_Authorizing Legislation_EBWP.docx Supplementary Document Uploaded 2013-12-02 Available
Att G-7_ScrShots of Train-the-Trainer Trainee Technical Assistance Survey.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att G-4_ ScrShots of Train-the-Trainer Participant Survey.docx Supplementary Document Uploaded 2013-12-02 Available
Att G-2_ScrShots of Train-the-Trainer Application Form.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att F-8_ ScrShots of Trainee Technical Assistance Survey.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att F-5_ScrShots of Trainee Reaction Survey Online Model.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att F-2_ScrShots of Trainee KAB Survey.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att E-8_ScrShots of Emplr Follow-up Survey.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att E-6_ScrShots Org Assessment.docx Supplementary Document Uploaded 2013-12-02 Repair queued
Att E-4_ScrShots Scorecard.docx Supplementary Document Uploaded 2013-12-02 Available
Att E-2_ScrShots of Empr Appl Form.docx Supplementary Document Uploaded 2013-12-02 Available
Work@Health Phase 2 SS_A.doc Supporting Statement A Uploaded 2013-12-02 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
213479 CDC Work@Health Trainee Technical Assistance Survey Form and Instruction New
213472 CDC Work@Health Train-the-Trainer Technical Assistance Survey Form and Instruction New
209594 CDC Work@Health Instructor/Coach Group Discussion Guide Other-WORD Unchanged
209593 CDC Work@Health Wave 2 Trainee Reaction Survey Other-WORD Modified
209592 CDC Word@Health Train-the Trainer Trainee Technical Assistance Survey Other-WORD Removed
209591 CDC Work @Health Train-the-Trainer Reaction Survey Other-WORD Modified
209590 CDC Work@Health Train-the-Trainer Participant Survey Other-WORD Modified
209589 CDC Work@Health Train-the-Trainer Application Form Other-WORD Modified
209588 CDC Work@Health Trainee Focus Group Discussion Guide Other-WORD Unchanged
209587 CDC Work @Health Case Study Interviews with Selected Trainees Other-WORD Unchanged
209586 CDC Work@Health Trainee Technical Assistance Survey Other-WORD Removed
209585 CDC Work@Health Trainee Reaction Survey Blended Model Other-WORD Modified
209584 CDC Work@Health Trainee Reaction Survey Online Model Other-WORD Unchanged
209583 CDC Work@Health Trainee Reaction Survey Hands-On Model Other-WORD Modified
209582 CDC Work@ Health Trainee KAB Survey Other-WORD Modified
209581 CDC Work@Health Case Study Interviews with Employees Other-WORD Unchanged
209580 CDC Work@Health Case Study Interviews with Senior Leadership Other-WORD Unchanged
209579 CDC Work@Health Employer Follow-up Survey Other-WORD Modified
209578 CDC Work Health Organizational Assessment Other-WORD Modified
209577 CDC Worksite Health Scorecard Other-WORD Modified
209576 CDC Work@Health Employer Application Form Other-WORD Unchanged
ICR Details
0920-1006 201410-0920-013
Historical Active 201312-0920-004
HHS/CDC 21040
CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 10/30/2014
Retrieve Notice of Action (NOA) 10/27/2014
  Inventory as of this Action Requested Previously Approved
01/31/2016 01/31/2016 01/31/2016
5,036 0 5,066
1,603 0 1,601
0 0 0
In the following Change Request for 0920-1006, CDC seeks OMB approval to increase the number of participants assigned to the train-the-trainer training model (and associated data collection), and reduce the number of participants assigned to two of the lower-demand employer training models (hands-on and blended) and associated data collections.
US Code: 42 USC 301 Name of Law: Public Health Service Act
   US Code: 42 USC 2801 Name of Law: Employer-based Wellness Program
  
None
Not associated with rulemaking
  78 FR 44564 07/24/2013
78 FR 71615 11/29/2013
No
  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 5,036 5,066 0 -30 0 0
Annual Time Burden (Hours) 1,603 1,601 0 2 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
Change in Burden Hours is the result of a redistribution of respondents that wish to receive a different training option.
$3,515,370
Yes Part B of Supporting Statement
Yes
Yes
No
No
Uncollected
Jeffrey Zirger 404 639-7118 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/27/2014