RETAIN Provider Surveys (R1 & R2)

Retaining Employment and Talent After Injury/Illness Network (RETAIN) demonstration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0821 can be found here:

Documents and Forms

Document Name Document Type
APPENDIX G - PROVIDER SURVEY INSTRUMENTS (R1, R2).pdf Other-RETAIN PROVIDER SURVEY INSTRUM
APPENDIX G - PROVIDER SURVEY INSTRUMENTS (R1, R2).pdf Other-RETAIN PROVIDER SURVEY INSTRUM
APPENDIX H - PROVIDER SURVEY MAILINGS (R1, R2).pdf Other-RETAIN PROVIDER SURVEY MAILING
APPENDIX H - PROVIDER SURVEY MAILINGS (R1, R2).pdf Other-RETAIN PROVIDER SURVEY MAILING
Provider Survey - Finalized Quetions (C15 - C18).pdf Other-Finalized Survey Questions C15
Provider Survey - Finalized Quetions (C15 - C18).pdf Other-Finalized Survey Questions C15
APPENDIX G - PROVIDER SURVEY INSTRUMENTS (R1, R2) - Current Version.pdf Current Provider Survey Questions (showing placeholders for C15-C18) IC Document
APPENDIX G - PROVIDER SURVEY INSTRUMENTS (R1, R2) - Current Version.pdf Current Provider Survey Questions (showing placeholders for C15-C18) IC Document

Information Collection (IC) Details

IC Title:	RETAIN Provider Surveys (R1 & R2)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-RETAIN PROVIDER SURVEY INSTRUMENTS (R1, R2)	APPENDIX G - PROVIDER SURVEY INSTRUMENTS (R1, R2).pdf	No	Paper Only
Other-RETAIN PROVIDER SURVEY MAILINGS (R1, R2)	APPENDIX H - PROVIDER SURVEY MAILINGS (R1, R2).pdf	No	Paper Only
Other-Finalized Survey Questions C15-C18	Provider Survey - Finalized Quetions (C15 - C18).pdf	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	190	190
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current Provider Survey Questions (showing placeholders for C15-C18)	APPENDIX G - PROVIDER SURVEY INSTRUMENTS (R1, R2) - Current Version.pdf	08/19/2022

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