WIPA Provider Survey

Ticket to Work Program Evaluation

Documents and Forms

Document Name Document Type
Attachment A2a - WIPA Provider Survey Invitation Letter (Week 1).docx Other-Survey Invitaton Email (Week 1
Attachment A2b - WIPA Provider Survey Invitation Email (Week 1.5).docx Other-Survey Invitation Email (Week
Attachment A2c - WIPA Provider Survey Reminder Email (Week 3).docx Other-Survey Invitation Email (Week
Attachment A2d - WIPA Provider Survey Reminder Email (Week 4.5).docx Other-Survey Invitation Email (Week
Attachment A2e - WIPA Provider Survey Reminder Email (Week 6).docx Other-Survey Invitation Email (Week
Attachment A2f - WIPA Provider Survey Reminder Email (Week 7.5).docx Other-Survey Invitation Email (Week
Attachment A2g - WIPA Provider Survey Instrument.docx Other-Survey Instrument

Information Collection (IC) Details

IC Title:	WIPA Provider Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey Invitaton Email (Week 1)	Attachment A2a - WIPA Provider Survey Invitation Letter (Week 1).docx	Yes	No	Printable Only
Other-Survey Invitation Email (Week 1.5)	Attachment A2b - WIPA Provider Survey Invitation Email (Week 1.5).docx	Yes	No	Printable Only
Other-Survey Invitation Email (Week 3)	Attachment A2c - WIPA Provider Survey Reminder Email (Week 3).docx	Yes	No	Printable Only
Other-Survey Invitation Email (Week 4.5)	Attachment A2d - WIPA Provider Survey Reminder Email (Week 4.5).docx	Yes	No	Printable Only
Other-Survey Invitation Email (Week 6)	Attachment A2e - WIPA Provider Survey Reminder Email (Week 6).docx	Yes	No	Printable Only
Other-Survey Invitation Email (Week 7.5)	Attachment A2f - WIPA Provider Survey Reminder Email (Week 7.5).docx	Yes	No	Printable Only
Other-Survey Instrument	Attachment A2g - WIPA Provider Survey Instrument.docx	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 59	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: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	59	59
Annual IC Time Burden (Hours)	37	37
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.