CDC Worksite Health Scorecard

Forms and Documents

Document Name	Status
Form 0920-1014 CDC Worksite Health Scorecard Form and Instruction	New
Form 0920-1014 CDC Worksite Health Scorecard Registration Form and Instruction	New
Form 0920-1014 CDC Worksite Health Scorecard Pilot Evaluation Form and Instruction	Removed
Form 0920-1014 CDC Worksite Health Scorecard Cognitive Interview Form and Instruction	Removed
Form 0920-1014 CDC Worksite Health Scorecard Form and Instruction	Removed
Form 0920-1014 CDC Worksite Health Scorecard- Registration Application Form and Instruction	Removed
rpt684_IRB_Form.pdf Supplementary Document	2019-02-12
NCCD Platform PIA - signed.pdf Supplementary Document	2019-02-12
CDC Worksite Health ScoreCard_Privacy Act Checklist.doc Supplementary Document	2019-02-12
Attachment_D_CDC Worksite Health Scorecard FAQs.docx Supplementary Document	2019-02-12
Attachment_C-5_CDC Scorecard_Summary of Revisions.docx Supplementary Document	2019-02-12
Attachment_C-4_CDC_Worksite_Scorecard_Resources for Action.pdf Supplementary Document	2019-02-12
Attachment_C-3_CDC Scorecard_Sample Benchmarking Report.pdf Supplementary Document	2019-02-12
Attachment_B-1_60_Day_FRN.pdf Supplementary Document	2019-02-12
Attachment A-2_Funding Authority ACA PPHF.pdf Supplementary Document	2019-02-12
Attachment A-1_Authorizing Legislation.docx Supplementary Document	2019-02-12
CDC Worksite Health Scorecard SS_A_1-28-19.docx Supporting Statement A	2019-02-12
CDC Worksite Health Scorecard SS_B_1-8-19 final.docx Supporting Statement B	2019-02-12

IC Document Collections

IC ID	Document Title	Status
234914	CDC Worksite Health Scorecard Form and Instruction	New
234913	CDC Worksite Health Scorecard Registration Form and Instruction	New
228461	CDC Worksite Health Scorecard Pilot Evaluation Form and Instruction	Removed
228460	CDC Worksite Health Scorecard Cognitive Interview Form and Instruction	Removed
228455	CDC Worksite Health Scorecard Form and Instruction	Removed
210319	CDC Worksite Health Scorecard- Registration Application Form and Instruction	Removed

ICR Details

OMB Control No: 0920-1014	ICR Reference No: 201901-0920-009
Status: Active	Previous ICR Reference No: 201709-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No: 14BE
Title: CDC Worksite Health Scorecard
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/29/2019
	Date Received in OIRA: 02/21/2019
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time CDC will request approval to extend or revise the collection if CDC seeks to continue the information collection activity beyond the period approved under this action.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved	03/31/2019
Responses	1,600	0	632
Time Burden (Hours)	667	0	306
Cost Burden (Dollars)	35,311	0	11,873

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Abstract: CDC will continue to provide for the ongoing usage of an updated version of the CDC Worksite Health Scorecard, web-based organizational assessment, by the employer community. The resulting data will be used to support research and increase understanding of the organizational programs, policies, and practices that employers of various sizes and industry sectors have implemented to support health lifestyle behaviors. It will also document changes in organizational practices over time and allow CDC to provide better technical assistance to employers seeking guidance on building or maintaining workplace health promotion programs.

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

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:
	83 FR 53252	10/22/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 4467	02/15/2019
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

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

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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	1,600	632	0	1,600	-632	0
Annual Time Burden (Hours)	667	306	0	667	-306	0
Annual Cost Burden (Dollars)	35,311	11,873	0	35,311	-11,873	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: There has been a slight increase in the total number of burden hours from 303 to 667 estimated annualized burden hours due predominately to an increase in the number of employer respondents from 200 for the pilot test to 800 for broader implementation. We also found during the pilot test that respondents took slightly more time to complete the registration (Attachment C-1) from an estimated 2 minutes to 5 minutes but a significantly shorter time to complete the Scorecard assessment (Attachment C-2) from an hour and 15 minutes to 45 minutes. The cognitive interview and pilot evaluation instruments used in the pilot have been dropped and are no longer needed for broader implementation reducing burden for these instruments.

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Annual Cost to Federal Government: $93,250

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: 02/21/2019

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