Information Collection Request

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH 2)

ICR 201211-0920-003 · OMB 0920-0953 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Survey to Improve Worker Notification Efforts #3 Form New Repair queued
Survey to Improve Worker Notification Efforts Form New Available
Fatigue Prevention Training Module Customer Satisfaction and Feedback Survey Form and Instruction New Repair queued
Form 0920-0953 The World Trade Center Health Program Customer Satisfaction Survey Form and Instruction New Available
Long Island WTC Health Program Survey Form New Available
North Shore LIJ Customer Satisfaction Survey Form and Instruction New Available
Form 0920-0953 The World Trade Center Health Program for Responders at Rutgers University Customer Satisfaction Survey Form and Instruction New Available
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey (Spanish and Polish versions) Form and Instruction New Available
Manual of Analytical Methods Customer Satisfaction Survey Form New Available
Generic_Clearance_Submission_Template[1].doc Supplementary Document Uploaded 2012-11-01 Available
NIOSH Part SS-B.docx Supporting Statement B Uploaded 2012-11-01 Available
NIOSH Part SS-A.docx Supporting Statement A Uploaded 2012-11-01 Available

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
12/31/2015 36 Months From Approved
334,500 0 0
86,250 0 0
0 0 0





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table that charts list of burden
IC Title Form No. Form Name
Logistics Health Incorporated (LHI)
Long Island WTC Health Program Survey none Long Island Patient Satisfaction Survey
North Shore LIJ Customer Satisfaction Survey None Medical Practice Survey
Fatigue Prevention Training Module Customer Satisfaction and Feedback Survey None NIOSH Fatigue Prevention Training Module Survey
The World Trade Center Health Program for Responders at Rutgers University Customer Satisfaction Survey 0920-0953 Patient Satisfaction Survey-Rutgers 12.10.13
Survey to Improve Worker Notification Efforts none Worker Notification Survey
Survey #2
Fatigue Management Training Module for Emergency Responders Evaluation
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey None World Trade Center Health Program Member Questionnaire
Survey to Improve Worker Notification Efforts #3 none Survey to Improve Worker Notification Efforts - #3
The World Trade Center Health Program Customer Satisfaction Survey 0920-0953, 0920-0953 WTC Customer Satisfaction Survey ,   WTC screen shots
Manual of Analytical Methods Customer Satisfaction Survey none Manual of Analytical Methods Survey
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey (Spanish and Polish versions) None, None Members in the WTCHP General Responders Consortium--Spanish Version ,   Members in the WTCHP General Responders Consortium Polish Version
Fatigue Management Training Module for Emergency Reponders Evaluation
The Nationwide Provider Network Customer Satisfaction Survey

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 334,500 0 0 334,500 0 0
Annual Time Burden (Hours) 86,250 0 0 86,250 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


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