Salt Sources Study

Forms and Documents

Document Name	Status
Study Salt Supplement Questionnaire Form	Modified
Follow-Up Urine Collection Questionnaire Form	Modified
24-Hour Urine Collection Form	Modified
Duplicate Salt Sample Collection Form	Modified
Food Record Form Form	Modified
24-Hour Dietary Recall Interview Form	Modified
Home Tap Water Questionnaire Form	Modified
Height and Weight Data Collection Form	Modified
Participant Questionnaire Form	Modified
Telephone Recruitment and Screening Form and Instruction	Modified
Discretionary Salt Use Form	Modified
0920-0982 Itemized List of Changes 5DEC13.docx Supplementary Document	2014-01-08
0920-0982 Change Request Justification 02Jan14.docx Justification for No Material/Nonsubstantive Change	2014-01-08
Att 17D_Study Salt Procedures for Study Staff_01082014.doc Supplementary Document	2014-01-09
Att 17C_Study Salt Record (completed by clinic staff)_01082014.doc Supplementary Document	2014-01-09
Att 17B_Study Salt Intr for Participants_01082014.docx Supplementary Document	2014-01-09
Att 16B_Criteria for Redo Collection (Instructions for Study Staff).doc Supplementary Document	2013-06-04
Att 15B_24 Hour Urine Collection Instructions_01082014.docx Supplementary Document	2014-01-09
Att 10B_Home Tap Water Collection Procedures for Study Staff.doc Supplementary Document	2013-06-04
Att 14B_Dup Salt Sample Collection Instr (Sub Study)_01082014.doc Supplementary Document	2014-01-09
Att 13C_Dup Salt Sample Collection Instr (non Sub Study)_01082014.docx Supplementary Document	2014-01-09
Att 13B_Dup Salt Sample Instr (Non Sub Study)_01082014.doc Supplementary Document	2014-01-09
Att 12B_Food Record Instructions_01082014.docx Supplementary Document	2014-01-09
Att 11B_Food Amounts Booklet.pdf Supplementary Document	2013-06-04
Att 8A_Dietary Recall Scheduling Form_01082014.docx Supplementary Document	2014-01-08
Att 4D_Study Fact Sheet_01082014.docx Supplementary Document	2014-01-08
Att 4C_Cover Letter-Phone Recruits_01082014.docx Supplementary Document	2014-01-08
Att 4B_Cover Letter-Those who cannot be reached by phone_01082014.docx Supplementary Document	2014-01-08

IC Document Collections

IC ID	Document Title	Status
207200	Study Salt Supplement Questionnaire Form	Modified
207199	Follow-Up Urine Collection Questionnaire Form	Modified
207198	24-Hour Urine Collection Form	Modified
207197	Water Collection Instruction	Modified
207196	Duplicate Salt Sample Collection Form	Modified
207195	Food Record Form Form	Modified
207194	24-Hour Dietary Recall Interview Form	Modified
207193	Home Tap Water Questionnaire Form	Modified
207192	Study Orientation Instruction	Modified
207191	Height and Weight Data Collection Form	Modified
207190	Participant Questionnaire Form	Modified
207189	Telephone Recruitment and Screening Form and Instruction	Modified
207188	Discretionary Salt Use Form	Modified

ICR Details

OMB Control No: 0920-0982	ICR Reference No: 201401-0920-004
Status: Historical Active	Previous ICR Reference No: 201306-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 21303
Title: Salt Sources Study
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/13/2014
	Date Received in OIRA: 01/09/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2015	09/30/2015	09/30/2015
Responses	4,890	0	4,890
Time Burden (Hours)	1,372	0	1,372
Cost Burden (Dollars)	0	0	0

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Abstract: CDC plans to conduct a two-year study to obtain current, accurate information about sources of dietary sodium including sodium inherent in foods, sodium in processed and restaurant foods, and salt added to food at the table and during cooking. Information will be collected from diverse groups of adults at three study sites in three distinct geographic regions. Minor changes are requested to several forms after a pilot period.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act-Research and Investigations
  

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

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 13

IC Title	Form No.	Form Name
24-Hour Urine Collection	none	24-hour Urine Collection
Follow-Up Urine Collection Questionnaire	none	Salt Sources Study--Follow-up Urine Collection Questionnaire
Study Salt Supplement Questionnaire	none	Study Salt Questionnaire
Discretionary Salt Use	None	Discretionary Salt Use Questions from NHANES 2009
Telephone Recruitment and Screening	none	4a - Telephone recruitment and screening
Participant Questionnaire	none	Participant Questionnaire
Height and Weight Data Collection	None	Height and Weight Form
Study Orientation
Home Tap Water Questionnaire	none	Home Tap Water Questionnaire
24-Hour Dietary Recall Interview	none	24-hour Dietary Recall
Food Record Form	none	Food Record
Duplicate Salt Sample Collection	none, none	Bag Label Salt Added at the Table ,   Bag Label Salt Added in Food Prep
Water Collection

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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	4,890	4,890	0	0	0	0
Annual Time Burden (Hours)	1,372	1,372	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $547,000

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? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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: 01/09/2014

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