WIC Local Agency Directors and WIC Clinic Staff - Profit/Non-Profit Businesses

WIC Nutrition Assessment and Tailoring Study

OMB: 0584-0663

IC ID: 244257

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0663 can be found here:

2022-03-22 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
C2_Local Agency Director Survey.docx Other-Appendix C2 Local Agency Direc
C2_Local Agency Director Survey.docx Other-Appendix C2 Local Agency Direc
C2a_Local Agency Director Survey Screenshots.pdf Other-Appendix C2a Local Agency Dire
C2a_Local Agency Director Survey Screenshots.pdf Other-Appendix C2a Local Agency Dire
C3_Call with Local Agency Director and Request Documents.docx Other-Appendix C3 Call with Local Ag
C3_Call with Local Agency Director and Request Documents.docx Other-Appendix C3 Call with Local Ag
C4_Clinic Site Information Form.xlsx Other-Appendix C4 Clinic Site Inform
C4_Clinic Site Information Form.xlsx Other-Appendix C4 Clinic Site Inform
C6_Site Director Interview Guide.docx Other-Appendix C6 Site Director Inte
C5_Site Director Interview Guide_4.6.21.docx Other-Appendix C5 Site Director Inte
C7a_Identified Risks Data Collection Form.docx Other-Appendix C7a Identified Risks
C6a_Identified Risks Data Collection Form_4.6.21.docx Other-Appendix C6a Identified Risks
C8_Staff Interview Guide.docx Other-Appendix C8 Staff Interview Gu
C7_Staff Interview Guide_remote_4.6.21.docx Other-Appendix C7 Staff Interview Gu
G4_Telephone Call with WIC Clinic.docx Other-Appendix G4 Telephone Call wit
G4_Telephone Call with WIC Clinic_remote_4.6.21.docx Other-Appendix G4 Telephone Call wit
G5_Informed Consent for Site Director Interview.docx Other-Appendix G5 Informed Consent f
G5_Informed Consent for Site Director Interview_remote_4.6.21.docx Other-Appendix G5 Informed Consent f
G6_Informed Consent for Observation and Staff Interview.docx Other-Appendix G6 Informed Consent f
G6_Informed Consent for Observation and Staff Interview_remote_4.6.21.docx Other-Appendix G6 Informed Consent f
E1_Introductory Email from SA to all LAs with Info Packet_AB 10212020.docx Appendix E1 Introductory Email from SA to all LAs with Info Packet IC Document
E1_Introductory Email from SA to all LAs with Info Packet_AB 10212020.docx Appendix E1 Introductory Email from SA to all LAs with Info Packet IC Document
E2_Email to LA with LA Director Survey Link.docx Appendix E2 Email to LA with LA Director Survey Link IC Document
E2_Email to LA with LA Director Survey Link.docx Appendix E2 Email to LA with LA Director Survey Link IC Document
E3_Reminder Emails to Complete LA Director Survey.docx Appendix E3 Reminder Emails to Complete LA Director Survey IC Document
E3_Reminder Emails to Complete LA Director Survey.docx Appendix E3 Reminder Emails to Complete LA Director Survey IC Document
F2_Site Visit Email from SA to Selected.docx Appendix F2 Site Visit Email from SA to Selected LA IC Document
F2_Site Visit Email from SA to Selected.docx Appendix F2 Site Visit Email from SA to Selected LA IC Document
F3_Site Visit Email to LA and Schedule Call.docx Appendix F3 Site Visit Email to LA and Schedule Call IC Document
F3_Site Visit Email to LA and Schedule Call.docx Appendix F3 Site Visit Email to LA and Schedule Call IC Document
F4_Reminder Email to Submit Nutrition Risk Assessment Documents.docx Appendix F4 Reminder Email to Submit Nutrition Risk Assessment Documents IC Document
F4_Reminder Email to Submit Nutrition Risk Assessment Documents.docx Appendix F4 Reminder Email to Submit Nutrition Risk Assessment Documents IC Document
G1_Email to LA with Selected Site Name.docx Appendix G1 Email to LA with Selected Site Name IC Document
G1_Email to LA with Selected Site Name.docx Appendix G1 Email to LA with Selected Site Name IC Document
G2_Site Visit Email from LA to WIC Clinic.docx Appendix G2 Site Visit Email from LA to WIC Clinic IC Document
G2_Site Visit Email from LA to WIC Clinic.docx Appendix G2 Site Visit Email from LA to WIC Clinic IC Document
G3_Site Visit Email to WIC Clinic and Schedule Call.docx Appendix G3 Site Visit Email to WIC Clinic and Schedule Call IC Document
G3_Site Visit Email to WIC Clinic and Schedule Call_remote_4.6.21.docx Appendix G3 Site Visit Email to WIC Clinic and Schedule Call IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	WIC Local Agency Directors and WIC Clinic Staff - Profit/Non-Profit Businesses	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Appendix C2 Local Agency Director Survey	C2_Local Agency Director Survey.docx	Yes	Yes	Fillable Fileable
Other-Appendix C2a Local Agency Director Survey (screenshots)	C2a_Local Agency Director Survey Screenshots.pdf	Yes	Yes	Fillable Fileable
Other-Appendix C3 Call with Local Agency Director and Request Documents	C3_Call with Local Agency Director and Request Documents.docx	Yes	No	Paper Only
Other-Appendix C4 Clinic Site Information Form	C4_Clinic Site Information Form.xlsx	Yes	Yes	Fillable Fileable
Other-Appendix C5 Site Director Interview Guide	C5_Site Director Interview Guide_4.6.21.docx	No		Paper Only
Other-Appendix C6a Identified Risks Data Collection Form	C6a_Identified Risks Data Collection Form_4.6.21.docx	No		Paper Only
Other-Appendix C7 Staff Interview Guide	C7_Staff Interview Guide_remote_4.6.21.docx	No		Paper Only
Other-Appendix G4 Telephone Call with WIC Clinic	G4_Telephone Call with WIC Clinic_remote_4.6.21.docx	Yes	No	Paper Only
Other-Appendix G5 Informed Consent for Site Director Interview	G5_Informed Consent for Site Director Interview_remote_4.6.21.docx	No		Paper Only
Other-Appendix G6 Informed Consent for Observation and Staff Interview	G6_Informed Consent for Observation and Staff Interview_remote_4.6.21.docx	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records
Title: FNS-8 USDA/FNS Studies and Reports	FR Citation: 56 FR 19078

Number of Respondents: 101	Number of Respondents for Small Entity: 98

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 13 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	561	561
Annual IC Time Burden (Hours)	162	162
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix E1 Introductory Email from SA to all LAs with Info Packet	E1_Introductory Email from SA to all LAs with Info Packet_AB 10212020.docx	10/28/2020
Appendix E2 Email to LA with LA Director Survey Link	E2_Email to LA with LA Director Survey Link.docx	10/28/2020
Appendix E3 Reminder Emails to Complete LA Director Survey	E3_Reminder Emails to Complete LA Director Survey.docx	10/28/2020
Appendix F2 Site Visit Email from SA to Selected LA	F2_Site Visit Email from SA to Selected.docx	10/28/2020
Appendix F3 Site Visit Email to LA and Schedule Call	F3_Site Visit Email to LA and Schedule Call.docx	10/28/2020
Appendix F4 Reminder Email to Submit Nutrition Risk Assessment Documents	F4_Reminder Email to Submit Nutrition Risk Assessment Documents.docx	10/28/2020
Appendix G1 Email to LA with Selected Site Name	G1_Email to LA with Selected Site Name.docx	10/28/2020
Appendix G2 Site Visit Email from LA to WIC Clinic	G2_Site Visit Email from LA to WIC Clinic.docx	10/28/2020
Appendix G3 Site Visit Email to WIC Clinic and Schedule Call	G3_Site Visit Email to WIC Clinic and Schedule Call_remote_4.6.21.docx	04/08/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.