Information Collection

Individual Worker Survey

IC 200237 under ICR 201111-0938-010 · OMB 0938-1160.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10404 Individual Worker Survey	Form and Instruction
CMS-10404 Individual Worker Survey CMS-10404 - Individual Worker Surveys and Materials 2-14-12 (2).doc	Form and Instruction

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 and Instruction	CMS-10404	Individual Worker Survey	CMS-10404 - Individual Worker Surveys and Materials 2-14-12 (2).doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	16,600	16,600
Annual IC Time Burden (Hours)	5,478	5,478
Annual IC Cost Burden (Dollars)	53,794	53,794

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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