Employee Health Assessment

National Healthy Worksite Program

OMB: 0920-0965

IC ID: 202683

Documents and Forms
Document Name
Document Type
Other-null
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Employee Health Assessment
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-null Attachment_F-2_NHWP_Employee_Health_Assessment.docx No   Printable Only

Health Public Health Monitoring

 

5,713 0
   
Individuals or Households
 
   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 11,426 0 11,426 0 0 0
Annual IC Time Burden (Hours) 2,857 0 2,857 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment_G-1_NHWP_Employee_Consent_Contact_Form Attachment_G-1_NHWP_Employee_Consent_Contact_Form.doc 03/26/2013
Attachment_C-5_NHWP Risk_Stratification_Logic Attachment_C-5_NHWP Risk_Stratification_Logic.docx 03/26/2013
Attachment_G-4_UnderstandingYourHealthScreeningResults Attachment_G-4_UnderstandingYourHealthScreeningResults.pdf 03/26/2013
Attachment_G-3_Physician_Referral_Form Attachment_G-3_Physician_Referral_Form.docx 03/26/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
© 2024 OMB.report | Privacy Policy