Information Collection

Survey #2

IC 216300 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⚠️ Notice: This information collection may be referencing outdated material.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
survey #2_web survey 3-31-15.docx	Other-WORD
Cover letter.docx	Instruction
Survey Screen Shots.pdf	Other-Screenshots
Request for Approval_Survey #2 docx.docx Request for Approval	IC Document

IC Title:

Survey #2

Agency IC Tracking Number:

15YN

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD	survey #2_web survey 3-31-15.docx	Yes	Yes	Fillable Printable
Instruction	Cover letter.docx	Yes	Yes	Fillable Fileable
Other-Screenshots	Survey Screen Shots.pdf	Yes	Yes	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	Request for Approval_Survey #2 docx.docx	04/27/2015

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