Information Collection

Healthcare Workers Screening Module

IC 192660 under ICR 201004-0920-008 · OMB 0920-0860.

Documents and Forms

Documents and forms in this information collection
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

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 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 %

table that charts list of burden
	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

table that charts IC Documents
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.