The World Trade Center (WTC) Health Program Customer Satisfaction Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH 2)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0953 can be found here:

Documents and Forms

Document Name Document Type
The World Trade Center (WTC) Health Program Customer Satisfaction Survey Form
World Trade Center Health Program Member Feedback Questi MemberSatisfactionSurvey2017NPN_Final.pdf Form
Cover Letter membersurvey.Final.docx Cover Letter for the WTC Member Feedback Questionnaire IC Document
Template App-WTC Member Survey2017.doc GenIC Template for WTC member customer satisfaction survey IC Document

Information Collection (IC) Details

IC Title:	The World Trade Center (WTC) Health Program Customer Satisfaction Survey	Agency IC Tracking Number:	0920-17WO

IC Status: New

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	N/A	World Trade Center Health Program Member Feedback Questionnaire	MemberSatisfactionSurvey2017NPN_Final.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: SORN 09-20-0147, Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH	FR Citation: 76 FR 31212

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	6,250	6,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letter for the WTC Member Feedback Questionnaire	Cover Letter membersurvey.Final.docx	03/16/2017
GenIC Template for WTC member customer satisfaction survey	Template App-WTC Member Survey2017.doc	03/16/2017

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