Nursing Home Administrators Committee Chair Interview

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

Documents and Forms

Document Name Document Type
Form 0920-0914 Nursing Home Administrators Committee Chair Interview Form
0920-0914 Committee Chair Interview Appendix C2.doc Form
0920-0914 Committee Chair Interview Online Appendix C2 online version.docx odu.co1.qualtrics.com/jfe/form/SV_bIRVNzuQ9y2M981 Form

Information Collection (IC) Details

IC Title:	Nursing Home Administrators Committee Chair Interview	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	0920-0914	Committee Chair Interview Online	Appendix C2 online version.docx	https://odu.co1.qualtrics.com/jfe/form/SV_bIRVNzuQ9y2M981	Yes	Yes	Fillable Fileable
Form	0920-0914	Committee Chair Interview	Appendix C2.doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	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.