CDC Worksite Health Scorecard

Forms and Documents

Document Name	Status
Form 0920-1014 CDC Worksite Health Scorecard Pilot Evaluation Form and Instruction	New
Form 0920-1014 CDC Worksite Health Scorecard Cognitive Interview Form and Instruction	New
Form 0920-1014 CDC Worksite Health Scorecard Form and Instruction	New
Form 0920-1014 CDC Worksite Health Scorecard- Registration Application Form and Instruction	Modified
CDC Worksite Health Scorecard SSA Final_11172017.docx Supporting Statement A	2017-11-17
Attachment_C-6_CDC_Worksite_Scorecard_Resources for Action_6.26.17.pdf Supplementary Document	2017-09-26
Attachment C-8_Employer recruitment email.docx Supplementary Document	2017-09-26
Attachment C-7_CDC_Worksite_Health Scorecard Summary of Revisions_6-26-17.docx Supplementary Document	2017-09-26
Attachment C-5_CDC Worksite Health ScoreCard Sample Benchmark Report_6.26.17.pdf Supplementary Document	2017-09-26
Attachment B-1 Federal Register Notice 60 day.pdf Supplementary Document	2017-09-26
Attachment A-2 Funding Authority ACA PPHF.pdf Supplementary Document	2017-09-26
Attachment A-1 Authorizing Legislation.docx Supplementary Document	2017-09-26
CDC Worksite Health Scorecard SS_B_4.24.2017_8-18-17.docx Supporting Statement B	2017-09-26

IC Document Collections

IC ID	Document Title	Status
228461	CDC Worksite Health Scorecard Pilot Evaluation Form and Instruction	New
228460	CDC Worksite Health Scorecard Cognitive Interview Form and Instruction	New
228455	CDC Worksite Health Scorecard Form and Instruction	New
210319	CDC Worksite Health Scorecard- Registration Application Form and Instruction	Modified

ICR Details

OMB Control No: 0920-1014	ICR Reference No: 201709-0920-008
Status: Historical Active	Previous ICR Reference No: 201402-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No: 14BE
Title: CDC Worksite Health Scorecard
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/02/2018
	Date Received in OIRA: 11/21/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2019	12 Months From Approved
Responses	632	0	0
Time Burden (Hours)	306	0	0
Cost Burden (Dollars)	11,873	0	0

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Abstract: The purpose of this data collection is to conduct a one year pilot test of an updated version of the CDC Worksite Health ScoreCard. Once an updated instrument is finalized, the intent is to offer it as an online application to employers to assess the number and type of evidence-based health promotion interventions or strategies that are part of their workplace health programs. The data is used by employers to identify gaps in current programming; benchmark individual employers results against other users of the system; and direct employers to worksite health tools and resources to support program planning, implementation, and evaluation. .

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act
   US Code: 42 USC 2801 Name of Law: Public Health and Welfare
  

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:
	82 FR 12354	03/02/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 217	11/13/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
CDC Worksite Health Scorecard- Registration Application	0920-1014	Attachment C-1_CDC Worksite Health Scorecard Registration Screenshots_6.26.17
CDC Worksite Health Scorecard Pilot Evaluation	0920-1014	Attachment C-4 CDC Worksite Scorecard Pilot Eval Screenshots_4.24.2017
CDC Worksite Health Scorecard Cognitive Interview	0920-1014	Attachment C-3 CDC Worksite Scorecard Cognitive Interview Guide_4.24.2017
CDC Worksite Health Scorecard	0920-1014	Attachment C-3 CDC Worksite Scorecard Cognitive Interview Guide_4.24.2017

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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	632	0	0	632	0	0
Annual Time Burden (Hours)	306	0	0	306	0	0
Annual Cost Burden (Dollars)	11,873	0	0	11,873	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 information collection serves as a pilot test of a revised Scorecard instrument which is being updated to ensure its scientific credibility. The burden estimate for the revised instrument is increasing to accommodate 31 additional questions. In addition there are 3 new ICs for a registration application process, cognitive interviews, and a pilot evaluation.

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Annual Cost to Federal Government: $446,500

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 11/21/2017

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