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Healthcare Worker - Follow-Up Survey
[NIOSH] Evaluation of Healthcare Worker Mental Health Campaign
OMB: 0920-1415
IC ID: 261470
OMB.report
HHS/CDC
OMB 0920-1415
ICR 202404-0920-001
IC 261470
( )
Documents and Forms
Document Name
Document Type
Healthcare Worker - Follow-Up Survey
Form and Instruction
Healthcare Worker - Follow-Up Survey
4 Healthcare worker follow-up survey.docx
Form and Instruction
Healthcare Worker - Follow-Up Survey
4 Healthcare worker follow-up survey.docx
Form and Instruction
0920-1415 Healthcare Worker - Follow-Up Survey
4 Healthcare worker follow-up survey_proposed changes_clean.docx
Form and Instruction
0920-1415 Healthcare Worker - Follow-Up Survey
4 Healthcare worker follow-up survey_proposed changes_clean.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Healthcare Worker - Follow-Up Survey
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
NA
Healthcare Worker - Follow-Up Survey
4 Healthcare worker follow-up survey.docx
NA
Yes
Yes
Fillable Fileable
Form and Instruction
0920-1415
Healthcare Worker - Follow-Up Survey
4 Healthcare worker follow-up survey_proposed changes_clean.docx
N/A
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Worker Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
12,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
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
12,000
0
0
0
0
12,000
Annual IC Time Burden (Hours)
2,000
0
0
0
0
2,000
Annual IC Cost Burden (Dollars)
6,435
0
0
0
0
6,435
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.