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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
National Food Study Pilot
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
Other-Household Screener_Spanish Version
B1a Household Screener_Spanish.docx
Yes
Yes
Fillable Fileable
Other-Initial Interview_English version
B2 Initial Interview.docx
Yes
Yes
Fillable Fileable
Other-Initial Interview_Spanish version
B2a Initial Interview_Spanish .docx
Yes
Yes
Fillable Fileable
Other-Food Log_English Version
B3 Food Log.docx
Yes
Yes
Fillable Fileable
Other-Food Log_Spanish Version
B3a Food Log_Spanish.docx
Yes
Yes
Fillable Fileable
Other-Income Worksheet_English Version
B4 Income Worksheet.docx
Yes
Yes
Fillable Fileable
Other-Income Worksheet_Spanish Version
B4a Income Worksheet_Spanish.docx
Yes
Yes
Fillable Fileable
Other-Meals and Snacks Form_English Version
B5 Meals and Snacks Form.docx
Yes
Yes
Fillable Fileable
Other-Meals and Snacks Form_Spanish Version
B5a Meals and Snacks Form_Spanish.docx
Yes
Yes
Fillable Fileable
Other-Nonresponse Followup_English Version
B6 Nonresponse Followup.docx
Yes
Yes
Fillable Fileable
Other-Nonresponse Followup_Spanish Version
B6a Nonresponse Followup_Spanish.docx
Yes
Yes
Fillable Fileable
Other-Final Interview _English Version
B7 Final Interview.docx
Yes
Yes
Fillable Fileable
Other-Final Interview _Spanish Version
B7a Final Interview_Spanish.docx
Yes
Yes
Fillable Fileable
Other-Respondent Feedback_English Version
B8 Respondent Feedback.docx
Yes
Yes
Fillable Fileable
Other-Respondent Feedback_Spanish Version
B8a Respondent Feedback_Spanish.docx
Yes
Yes
Fillable Fileable
Other-Recall Interview_English Version
B9 Recall Interview.docx
Yes
Yes
Fillable Fileable
Other-Household Screener_English Version
B1 Household Screener.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Community and Social Services
Subfunction:
Social Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
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
2,500
0
2,500
0
0
0
Annual IC Time Burden (Hours)
6,575
0
6,575
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
A6 Westat Confidentiality and Nondisclousure Agreement
A6 Westat Confidentiality and Nondisclousure Agreement.pdf
08/24/2016
A7 Westat IRB Approval
A7 Westat IRB Approval.docx
08/24/2016
A8a 60 Day FRN
A8a 60 Day FRN.pdf
08/24/2016
A9 Pretest Report
A9 Pretest Report.pdf
09/21/2016
ERS Response to NASS Comments
Response to NASS Comments 081116.docx
08/24/2016
A1 Advance letter_English Version
A1 Advance letter.docx
09/21/2016
A1a Advance letter_Spanish Version
A1a Advance letter_Spanish.doc
09/21/2016
A2 Information Sheet_English Version
A2 Information Sheet _English_09212016.doc
09/21/2016
A2a Information Sheet_Spanish Version
A2a Information Sheet _Spanish.doc
09/21/2016
A5a Parental Consent Form_English Version
A5a Parental Consent Form.docx
09/21/2016
A5b Individual Assent-Consent Form_English Version
A5b Individual Assent-Consent Form.docx
09/21/2016
A5ba Individual Assent-Consent Form_Spanish Version
A5ba Individual Assent-Consent Form_Spanish.doc
09/21/2016
A3 Disclaimer
A3 Disclaimer.docx
12/06/2016
A3a Disclaimer_Spanish
A3a Disclaimer_Spanish.doc
12/06/2016
A4 Consent Form_English Version
A4 Consent Form.docx
12/06/2016
A4a Consent Form_Spanish Version
A4a Consent Form_Spanish.doc
12/06/2016
A5a Parental Consent Form_English Version
A5a Parental Consent Form.docx
12/06/2016
A5aa Parental Consent Form_Spanish
A5aa Parental Consent Form_Spanish.doc
12/06/2016
ERS respose to omb passback
ERS respose to omb passback.docx
12/06/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.