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Survey
National Survey of Community-based Policy and Environmental Supports for Healthy Eating and Active Living
OMB: 0920-1007
IC ID: 209574
OMB.report
HHS/CDC
OMB 0920-1007
ICR 201312-0920-003
IC 209574
( )
Documents and Forms
Document Name
Document Type
Survey
Form
Survey - screenshots
Appendix C2 Screenshots of Survey Questionnaire_Revised _120313..pdf
Form
Survey - Word
Appendix C1 CBS National Survey_Questionaire_Revised 120313.docx
Form
Appendix D1 Study_Invitation_Letter_10 28 2013.docx
D1 - Invitation Letter
IC Document
Appendix D2 Study Fact Sheet_12032013.docx
D2 - Study Fact Sheet
IC Document
Appendix D3 Instructions for Accessing the Web Survey_12032013.docx
D3 - Instructions for Accessing Survey
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Survey
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
none
Survey - screenshots
Appendix C2 Screenshots of Survey Questionnaire_Revised _120313..pdf
Yes
Yes
Fillable Fileable
Form
none
Survey - Word
Appendix C1 CBS National Survey_Questionaire_Revised 120313.docx
No
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,139
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
98 %
Approved
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
3,139
0
3,139
0
0
0
Annual IC Time Burden (Hours)
1,570
0
1,570
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
D1 - Invitation Letter
Appendix D1 Study_Invitation_Letter_10 28 2013.docx
12/04/2013
D2 - Study Fact Sheet
Appendix D2 Study Fact Sheet_12032013.docx
12/04/2013
D3 - Instructions for Accessing Survey
Appendix D3 Instructions for Accessing the Web Survey_12032013.docx
12/04/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.