World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0953 can be found here:

Documents and Forms

Document Name Document Type
WTCHP- Telephone Script.docx Instruction
World Trade Center Health Program Member Questionnaire WTCHP Questionnaire.docx Form and Instruction
WTCHP fast track form.doc WTCHP fast track form IC Document

Information Collection (IC) Details

IC Title:	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	Agency IC Tracking Number:

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
Instruction			WTCHP- Telephone Script.docx		Yes	No	Paper Only
Form and Instruction	None	World Trade Center Health Program Member Questionnaire	WTCHP Questionnaire.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,319	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1,319	0	0	0	0	0
Annual IC Time Burden (Hours)	165	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
WTCHP fast track form	WTCHP fast track form.doc	06/05/2013

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