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Paper-based Initial Survey
Gulf Oil Spill Worker Rostering Survey
OMB: 0920-0851
IC ID: 192873
OMB.report
HHS/CDC
OMB 0920-0851
ICR 201005-0920-007
IC 192873
( )
Documents and Forms
Document Name
Document Type
Form No number
Paper-based Initial Survey
Form
No number Paper-based Survey
NIOSH_Intake_Survey_052810.doc
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Paper-based Initial Survey
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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
Form
No number
Paper-based Survey
NIOSH_Intake_Survey_052810.doc
Yes
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
6,500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
6,500
0
0
0
0
6,500
Annual IC Time Burden (Hours)
541
0
-1,084
0
0
1,625
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.