Healthcare Workers Screening Module

Survey of Healthcare Workers' Health and Safety Practices

Documents and Forms

Document Name Document Type
Form 2 Healthcare Workers Screening Module Form and Instruction
2 Healthcare Workers Screening Module Attachment I1_Screening Module_FINAL_08042010.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Healthcare Workers Screening Module	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	2	Healthcare Workers Screening Module	Attachment I1_Screening Module_FINAL_08042010.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,650	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,650	25,650
Annual IC Time Burden (Hours)	428	428
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.