Information Collection

Employee Eligiblity File Format Requirements

IC 202674 under ICR 201303-0920-012 · OMB 0920-0965.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_E-2_Employee_Eligibility_File.docx	Other-null
Attachment_D-1_NHWP Eligibility Requirements.docx Attachment_D-1_NHWP Eligibility Requirements	IC Document
Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices1 doc.pdf Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices	IC Document
Attachment_G-3_Physician_Referral_Form.docx Attachment_G-3_Physician_Referral_Form	IC Document
Attachment_G-4_UnderstandingYourHealthScreeningResults.pdf Attachment_G-4_UnderstandingYourHealthScreeningResults	IC Document
Attachment_G-5_NHWP_Employee_FAQ.doc Attachment_G-5_NHWP_Employee_FAQ	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-null			Attachment_E-2_Employee_Eligibility_File.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 38

Number of Respondents for Small Entity: 13

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	152	152
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment_D-1_NHWP Eligibility Requirements	Attachment_D-1_NHWP Eligibility Requirements.docx	03/26/2013
Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices	Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices1 doc.pdf	05/08/2013
Attachment_G-3_Physician_Referral_Form	Attachment_G-3_Physician_Referral_Form.docx	03/26/2013
Attachment_G-4_UnderstandingYourHealthScreeningResults	Attachment_G-4_UnderstandingYourHealthScreeningResults.pdf	03/26/2013
Attachment_G-5_NHWP_Employee_FAQ	Attachment_G-5_NHWP_Employee_FAQ.doc	03/26/2013

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