Healthy Weight Collaborative

Forms and Documents

Document Name	Status
Form 1 Healthy Weight Collaborative Form	New
Supporting Statement B.pdf Supporting Statement B	2013-01-08
Affordable Care Act of 2010.docx Supplementary Document	2012-10-04
Supporting Statement A.docx Supporting Statement A	2013-03-12

IC Document Collections

IC ID	Document Title	Status
204420	Healthy Weight Collaborative Form	New

ICR Details

OMB Control No: 0915-0358	ICR Reference No: 201210-0915-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Healthy Weight Collaborative
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: 03/20/2013
	Date Received in OIRA: 10/10/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved
Responses	103	0	0
Time Burden (Hours)	136	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: As part of Collaborate for Healthy Weight, in collaboration with HRSA and a coalition of partner organizations, NICHQ has created the Healthy Weight Collaborative (HWC) to identify model approaches linking clinical services, public health functions, and other community services to address childhood and family obesity. The HWC aims to prevent and treat childhood obesity by working with 50 community teams to identify, test, and evaluate a national HWC change package of evidence-based program and policy interventions. HRSA is seeking OMB clearance to gather information from the HWC community teams and NICHQ leaders, staff, and faculty in order to conduct an implementation study of Phase 2 of program implementation of the HWC project. The goal of the implementation study is to document the ongoing development and refinement of the HWC project's "change package," in Phase 2 of program implementation of the project, as well as the adaptation of the project's learning collaborative process in a virtual format with no in-person meetings. The study will also document the participation of the 40 Phase 2 community teams, their experiences, and their results.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 10401 Name of Law: Affordable Care Act of 2010
   PL: Pub.L. 111 - 148 4002 Name of Law: Affordable Care Act of 2010
  

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 44257	07/27/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 60127	10/02/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Healthy Weight Collaborative	1, 2, 3, 4	Phase 1 interviews ,   Phase 2 ,   NICHQ ,   observation template

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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	103	0	0	103	0	0
Annual Time Burden (Hours)	136	0	0	136	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.

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Annual Cost to Federal Government: $160,165

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? No

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

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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: 10/10/2012

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