Information Collection

The World Trade Center Health Program Customer Satisfaction Survey

IC 212365 under ICR 201211-0920-003 · OMB 0920-0953.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0953 The World Trade Center Health Program Customer Satisfaction Survey	Form and Instruction
0920-0953 WTC Customer Satisfaction Survey WTC Customer Satisfaction Survey.doc	Form and Instruction
0920-0953 WTC screen shots WTC screen shots.pdf	Form and Instruction
English version.docx English version	IC Document
Spanish version.docx Spanish version	IC Document
Polish version.doc Polish version	IC Document
Chinese version.doc Chinese version	IC Document

IC Title:

The World Trade Center Health Program Customer Satisfaction Survey

Agency IC Tracking Number:

0920-095314AOR

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	0920-0953	WTC Customer Satisfaction Survey	WTC Customer Satisfaction Survey.doc		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0953	WTC screen shots	WTC screen shots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Federal Register Citation

FR Citation: 79 FR 24432

Number of Respondents: 6,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,500	6,500
Annual IC Time Burden (Hours)	1,083	1,083
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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