Home Care Worker Interest Response Form

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

Documents and Forms

Document Name Document Type
Att D2_Recruitment Response Form.doc Other-WORD
Att D1_Recruitment Info.doc Att D1_Recruitment Info IC Document

Information Collection (IC) Details

IC Title:	Home Care Worker Interest Response Form	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 D2_Recruitment Response Form.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att D1_Recruitment Info	Att D1_Recruitment Info.doc	11/01/2010

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