Nurse Survey

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0914 can be found here:

Documents and Forms

Document Name Document Type
Nurse Survey Form
Nurse Survey Nurse Survey 5 24 2012 (2).doc Form
Appendix F updated 9.30.11.docx Nurse Letter of Introduction IC Document

Information Collection (IC) Details

IC Title:	Nurse Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Form	none	Nurse Survey	Nurse Survey 5 24 2012 (2).doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,000	2,000	2,000
Annual IC Time Burden (Hours)	1,333	666	667
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Nurse Letter of Introduction	Appendix F updated 9.30.11.docx	10/13/2011

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