Information Collection

Employer Questionnaire

IC 194325 under ICR 201008-0920-011 · OMB 0920-0875.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Employer Questionnaire	Form
Employer Questionnaire Attachment F Employer Questionnaire (Phases I and II).doc	Form
Attachment F Employer Questionnaire Attachment F Employer Questionnaire Dec 2 revised.doc	Form
Attachment H Follow-up Ltrs for Employers & Providers.doc Follow-up Letter for non-respondents	IC Document
Attachment I-1 Employer Phone Follow-up Prompt & Questionnaire (Phases I&II).doc Employer Phone Follow-up	IC Document

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	None	Attachment F Employer Questionnaire	Attachment F Employer Questionnaire Dec 2 revised.doc		Yes	Yes	Fillable Fileable
Form	None	Employer Questionnaire	Attachment F Employer Questionnaire (Phases I and II).doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

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	400	400
Annual IC Time Burden (Hours)	213	213
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Follow-up Letter for non-respondents	Attachment H Follow-up Ltrs for Employers & Providers.doc	08/04/2010
Employer Phone Follow-up	Attachment I-1 Employer Phone Follow-up Prompt & Questionnaire (Phases I&II).doc	08/04/2010

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