Hospital Administrators Evaluation Form

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0914 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0914 Hospital Administrators Evaluation Form Form and Instruction
0920-0914 Attachment C1 Cleant Clean Copy C1 7-21-15.docx Form and Instruction
Highlighted Copy C1 7-21-15.docx Highlighted Copy C1 7-21-15 IC Document

Information Collection (IC) Details

IC Title:	Hospital Administrators Evaluation Form	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 and Instruction	0920-0914	Attachment C1 Cleant	Clean Copy C1 7-21-15.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17	0	17
Annual IC Time Burden (Hours)	18	1	17
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Highlighted Copy C1 7-21-15	Highlighted Copy C1 7-21-15.docx	07/21/2015

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