Information Collection

Employer screener

IC 194324 under ICR 201008-0920-011 · OMB 0920-0875.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Employer screener	Form
Employer screener Attachment C Employer Screener (Phases I and II).doc	Form
Attachment D Employer Invitation Letter (Phases I and II).doc Employer invitation letter	IC Document

IC Title:

Employer screener

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	none	Employer screener	Attachment C Employer Screener (Phases I and II).doc		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,425

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	7,425	7,425
Annual IC Time Burden (Hours)	619	619
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Employer invitation letter	Attachment D Employer Invitation Letter (Phases I and II).doc	08/04/2010

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