Employee Eligiblity File Format Requirements

National Healthy Worksite Program

Documents and Forms

Document Name Document Type
Attachment_E-2_Employee_Eligibility_File.docx Other-null
Attachment_D-1_NHWP Eligibility Requirements.docx Attachment_D-1_NHWP Eligibility Requirements IC Document
Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices1 doc.pdf Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices IC Document
Attachment_G-3_Physician_Referral_Form.docx Attachment_G-3_Physician_Referral_Form IC Document
Attachment_G-4_UnderstandingYourHealthScreeningResults.pdf Attachment_G-4_UnderstandingYourHealthScreeningResults IC Document
Attachment_G-5_NHWP_Employee_FAQ.doc Attachment_G-5_NHWP_Employee_FAQ IC Document

Information Collection (IC) Details

IC Title:	Employee Eligiblity File Format Requirements	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
Other-null			Attachment_E-2_Employee_Eligibility_File.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 38	Number of Respondents for Small Entity: 13

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	152	152
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment_D-1_NHWP Eligibility Requirements	Attachment_D-1_NHWP Eligibility Requirements.docx	03/26/2013
Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices	Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices1 doc.pdf	05/08/2013
Attachment_G-3_Physician_Referral_Form	Attachment_G-3_Physician_Referral_Form.docx	03/26/2013
Attachment_G-4_UnderstandingYourHealthScreeningResults	Attachment_G-4_UnderstandingYourHealthScreeningResults.pdf	03/26/2013
Attachment_G-5_NHWP_Employee_FAQ	Attachment_G-5_NHWP_Employee_FAQ.doc	03/26/2013

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