Special Data Request

EXAMPLE

Form Approved

OMB No. 0920-1053

Exp. Date xx/xx/xxxx

Special Data Request

For Cooperative Agreement Awardees

(Centers for Disease Control and Prevention / Division of Community Health)

Public reporting burden of this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-1053)

CDC is requesting additional information about ________________ in order to _____________________. Please answer the following questions and return this form to ______________________ by __________.

Awardee Name
AMO ID#		AMO Title: Increase the number of schools in County A with new healthy food options that are consistent with the Institute of Medicine’s Nutrition Standards for Foods in Schools from X to Y by date.			AMO Description
#	Item	Instructions		AMO	Setting 1
1	Every resident	Is this AMO being implemented across all geographic areas included in your DCH award with the potential to reach every resident?
2	Rural	Is this AMO taking place in a rural setting?
3	County or city/town name(s)	Please identify the county or city/town name(s) in which this AMO is being implemented.
4	Zip code(s)	Please identify the zip code(s) that are being targeted by this AMO.
5	Number of people reached	Please specify the total number of people who will be reached by this AMO.
6	Total number of possible people	Please specify the total number of possible people who could be reached by this AMO.
7	Setting	In which type of setting is this AMO taking place?
8	Number of units of Setting	How many units of the setting are included?
Of the total number of people, how many are:
9	Low-income	How many low-income individuals are reached by this AMO?
10	Age	Please specify the total number of individuals reached by this AMO in each of the following age categories.	Under 5 years
			5-9 years
			10-14 years
			15-19 years
			20-24 years
			65+
11	Ethnicity	Please specify the total number of individuals reached by this AMO in each of the following race and ethnicity categories.	Hispanic
	Race/		Black or African American
			Asian
			American Indian or Alaska Native
			Native Hawaiian or Other Pacific Islander