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 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	Survey Pretest	Attachment C-2 Workplace Hlt Haz Survey.doc		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	Attachment C-1 Letter of Invitation Revised.doc	10/28/2008
Question Matrix	Attachment C-3 Research Question Matrix.doc	10/28/2008

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