Client Pre Survey (English, Spanish, and Chinese)

Survey to Evaluate Occupational and Safety Educational Materials for Home Care Workers

Documents and Forms

Document Name Document Type
Att C3- Client pre survey OMBcomments.docx Other-WORD
Att I_Consent documents.doc Att I_Consent documents IC Document
Att I- Consent Documents (3).docx Att I- Consent Documents (3) IC Document

Information Collection (IC) Details

IC Title:	Client Pre Survey (English, Spanish, and Chinese)	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
Other-WORD			Att C3- Client pre survey OMBcomments.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 320	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att I_Consent documents	Att I_Consent documents.doc	11/01/2010
Att I- Consent Documents (3)	Att I- Consent Documents (3).docx	03/08/2011

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