Healthcare Workers Core Module

Survey of Healthcare Workers' Health and Safety Practices

Documents and Forms

Document Name Document Type
Form 10 Healthcare Workers Core Module Form and Instruction
10 Healthcare Workers Core Module Attachment I9_Core Module_TC_72310.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Healthcare Workers Core 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	10	Healthcare Workers Core Module	Attachment I9_Core Module_TC_72310.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,520	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	20,520	20,520
Annual IC Time Burden (Hours)	6,840	6,840
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.