Respondents completing paper survey

Survey of Coal Mine Safety Interventions

Documents and Forms

Document Name Document Type
Appendix B Questionnaire.doc Instruction
Appendix D Cover Letter .doc Appendix D Cover letter IC Document

Information Collection (IC) Details

IC Title:	Respondents completing paper survey	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
Instruction			Appendix B Questionnaire.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 144	Number of Respondents for Small Entity: 144

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	144	144
Annual IC Time Burden (Hours)	72	72
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix D Cover letter	Appendix D Cover Letter .doc	04/05/2010

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