Evaluation Form - Administrators

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⚠️ Notice: This information collection may be referencing outdated material.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
Evaluation Form - Administrators Form
Evaluation Form 10 7 2011attachment-C1.docx Form
Appendix D updated 9.30.11.docx Letter of Introduction and Fact Sheet IC Document

Information Collection (IC) Details

IC Title:	Evaluation Form - Administrators	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	Evaluation Form	10 7 2011attachment-C1.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter of Introduction and Fact Sheet	Appendix D 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.