OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 201512-0920-008 · OMB 0920-1006 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Trainee Technical Assistance Survey Form Modified Available
Train-the-Trainer Technical Assistance Survey Form Modified Available
Instructor/Coach Group Discussion Guide Form and Instruction Modified Available
Wave 2 Trainee Reaction Survey Form Modified Available
Train-the-Trainer Reaction Survey Form Modified Available
Train-the-Trainer Participant Survey Form Modified Available
Train-the-Trainer Application Form Form Modified Available
Trainee Focus Group Discussion Guide Form and Instruction Modified Available
Case Study Interviews with Selected Trainees Form and Instruction Modified Available
Trainee Reaction Survey Blended Model Form Modified Available
Trainee Reaction Survey - Online Model Form Modified Available
Trainee Reaction Survey- Hands-On Model Form Modified Available
Trainee KAB Survey Form Modified Available
Case Study Interviews with Employees Form and Instruction Modified Available
Case Study Interviews with Senior Leadership Form and Instruction Modified Available
Employer Follow-up Survey Form Modified Repair queued
Organizational Assessment Form Modified Available
CDC Worksite Health Scorecard Form Modified Available
Employer Application Form Form Modified Available
Work@Health Extension SS_B 12-18-15.doc Supporting Statement B Uploaded 2016-01-06 Available
Work@Health SS_A 01062016.doc Supporting Statement A Uploaded 2016-01-06 Repair queued
Att J_Employer Training_FAQ.doc Supplementary Document Uploaded 2015-12-21 Available
Att D_Data Collection Flowchart_12-14-15.doc Supplementary Document Uploaded 2015-12-21 Available
Att C_Objective-Survey Instrument Crosswalk.doc Supplementary Document Uploaded 2015-12-21 Available
Att B-2_Summary of Public Comments.docx Supplementary Document Uploaded 2015-12-21 Available
Att B-1_60-day FRN 8 04 2015.pdf Supplementary Document Uploaded 2015-12-21 Repair queued
A-3_PHSA Rsch.pdf Supplementary Document Uploaded 2015-12-21 Available
A-2_Funding Authority_ACA.pdf Supplementary Document Uploaded 2015-12-21 Available
A-1_Authorizing Legislation_EBWP.docx Supplementary Document Uploaded 2015-12-21 Available
IC Document Collections
IC IDCollectionTypeStatusForm
213479 Trainee Technical Assistance Survey Form Modified
213472 Train-the-Trainer Technical Assistance Survey Form Modified
209594 Instructor/Coach Group Discussion Guide Form and Instruction Modified
209593 Wave 2 Trainee Reaction Survey Form Modified
209591 Train-the-Trainer Reaction Survey Form Modified
209590 Train-the-Trainer Participant Survey Form Modified
209589 Train-the-Trainer Application Form Form Modified
209588 Trainee Focus Group Discussion Guide Form and Instruction Modified
209587 Case Study Interviews with Selected Trainees Form and Instruction Modified
209585 Trainee Reaction Survey Blended Model Form Modified
209584 Trainee Reaction Survey - Online Model Form Modified
209583 Trainee Reaction Survey- Hands-On Model Form Modified
209582 Trainee KAB Survey Form Modified
209581 Case Study Interviews with Employees Form and Instruction Modified
209580 Case Study Interviews with Senior Leadership Form and Instruction Modified
209579 Employer Follow-up Survey Form Modified
209578 Organizational Assessment Form Modified
209577 CDC Worksite Health Scorecard Form Modified
209576 Employer Application Form Form Modified
ICR Details
0920-1006 201512-0920-008
Historical Active 201410-0920-013
HHS/CDC 21040
CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation
Revision of a currently approved collection   No
Regular
Approved without change 03/30/2016
Retrieve Notice of Action (NOA) 01/11/2016
  Inventory as of this Action Requested Previously Approved
03/31/2019 36 Months From Approved 03/31/2016
3,310 0 5,036
1,044 0 1,603
0 0 0
Through the Work@Health Program, CDC provides training and technical assistance to employers to strengthen science-based worksite health programs and employee engagement in these programs. Information is collected for program administration and evaluation.
US Code: 42 USC 2801 Name of Law: Employer-based Wellness Program
   PL: Pub.L. 111 - 148 1001 Name of Law: Affordable Care Act
   US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  80 FR 46282 08/04/2015
80 FR 79591 12/22/2015
Yes
  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 3,310 5,036 0 -1,726 0 0
Annual Time Burden (Hours) 1,044 1,603 0 -559 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
Burden reduction is primarily due to annualizing the burden over three years, instead of two. There are additional reductions due to reducing the number of respondents for two ICs.
$2,709,724
Yes Part B of Supporting Statement
Yes
Yes
No
No
Uncollected
Shari Steinberg 404 639-4942 [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.
01/11/2016