OMB control number

National Healthy Worksite Program

OMB 0920-0965 · HHS/CDC.

OMB 0920-0965

Latest Forms, Documents, and Supporting Material

Document Name
Attachment_I-2_IRB_RTIRequest_for_Exemption.pdf Supplementary Document
Attachment_I-1_IRB VHMRequest_for_Exemption.pdf Supplementary Document
Summary of Major Changes_3 06 2013.docx Supplementary Document
Attachment_C-5_NHWP Risk_Stratification_Logic.docx Supplementary Document
Attachment_C-4_NHWP_Data_Flow_Diagram_Program Provider.pdf Supplementary Document
Attachment_C-3_Employer_Employees_Data_Flow_Diagram_Revised_12_11_12.pdf Supplementary Document
Attachment_C-2_Projected Profile of NHWP Employer-Employee Participation.docx Supplementary Document
Attachment_C-1_NHWP_Program_Objective_Survey_Instrument_Crosswalk_Overview_and_DetailSheets.pdf Supplementary Document
Attachment_B-3_NHWP_Federal_Register_Notice_Program_Announcement.pdf Supplementary Document
Attachment_B-2_Summary of Public Comments.pdf Supplementary Document
Attachment_B-1_Federal_Register_Notice_60 Day.pdf Supplementary Document
Attachment_A-2_Authorizing_Legislation_PHSA.pdf Supplementary Document
NHWP_SS_Part_B_3_5_13.docx Supporting Statement B
NHWP_SS_Part_A_3_5_13.docx Supporting Statement A
Attachment_A-1_-Authorizing_Legislation.pdf Supplementary Document
All Employee Survey Other-null
Health Screening Consent / Contact Form Other-null
Nutrition and Physical Activity Tracker Log / Health Tracker Other-null
Feel Fit with Fiber Challenge Log Other-null
Quench Your Thirst Challenge Log Other-null
Mix It Up Challenge Log Other-null
Maintain Don't Gain Challenge Log Other-null
Step into Health Challenge Log Other-null
Lower Your Weight by Eight Challenge Log Other-null
Employee Satisfaction Survey Other-null
Employee Success Story Consent Form Other-null
Employee Health Assessment Other-null
Community Participant Emgagement Feedback Survey Other-null
Worksite Health 101 Training Survey: Part IV Other-null
Worksite Health 101 Training Survey: Part I-III Other-null
Employer Follow-Up Survey Other-null
Employer Discussion Guide: Wellness Committee (Case Studies) Other-null
Employer Discussion Guide: Steering Committee Members (Case Studies) Other-null
Health Screening Site Interview Form Other-null
Employer Information Form Other-null
Employee Eligiblity File Format Requirements Other-null
Organizational Assessment (Employer) Other-null
Employer Phone Interview Guide Other-null

All Historical Document Collections

201303-0920-012 Approved with change	New collection (Request for a new OMB Control Number)	2013-03-26
201206-0920-002 Withdrawn	New collection (Request for a new OMB Control Number)	2012-06-13