Information Collection

Customer Survey Pretest

IC 187115 under ICR 200811-0920-002 · OMB 0920-0803.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form no number Survey Pretest Customer Survey Pretest	Form
no number Survey Pretest Attachment C-2 Workplace Hlt Haz Survey.doc	Form
Attachment C-1 Letter of Invitation Revised.doc Invitation Letter	IC Document
Attachment C-3 Research Question Matrix.doc Question Matrix	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	no number				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	32	32
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Invitation Letter		10/28/2008
Question Matrix		10/28/2008

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

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