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Communities
The Jackson Heart Study: Annual Follow-up with Third Party Respondents (NHLBI)
OMB: 0925-0491
IC ID: 205559
OMB.report
HHS/NIH
OMB 0925-0491
ICR 201301-0925-002
IC 205559
( )
Documents and Forms
Document Name
Document Type
Form 1
Communities
Form and Instruction
1 Pre-Post Testing Forms CHAN
Attachment 1 -Pre-Post Testing CHAN.docx
Form and Instruction
2 My Habits Pre-Post test
Attachment 2-My Habits Pre-Post Test.docx
Form and Instruction
3 CHA Diary
Attachment 3 - CHA Diary.doc
Form and Instruction
4 Train the Trainer Pre-Post Test
Attachment 4 - Train the Trainer Pre-Post Test.docx
Form and Instruction
5 Checklist
Attachment 5-Checklists.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Communities
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
1
Pre-Post Testing Forms CHAN
Attachment 1 -Pre-Post Testing CHAN.docx
No
No
Paper Only
Form and Instruction
2
My Habits Pre-Post test
Attachment 2-My Habits Pre-Post Test.docx
No
No
Paper Only
Form and Instruction
3
CHA Diary
Attachment 3 - CHA Diary.doc
No
No
Paper Only
Form and Instruction
4
Train the Trainer Pre-Post Test
Attachment 4 - Train the Trainer Pre-Post Test.docx
No
No
Printable Only
Form and Instruction
5
Checklist
Attachment 5-Checklists.docx
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
78
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
780
0
780
0
0
0
Annual IC Time Burden (Hours)
1,170
0
1,170
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.