Interested Employer - Pilot Employer Application Form

CDC Work@Health Program: Phase 1

Documents and Forms

Document Name Document Type
Interested Employer - Pilot Employer Application Form Form
Pilot Employer Application Form Attachment I-2_Screen Shots Pilot Employer Application Form_6-27-13.doc Form
Attachment I-1_Pilot Employer Application Form_6-25-13.doc Pilot Employer Application Form IC Document

Information Collection (IC) Details

IC Title:	Interested Employer - Pilot Employer Application Form	Agency IC Tracking Number:

Is this a Common Form? No		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
Form	none	Pilot Employer Application Form	Attachment I-2_Screen Shots Pilot Employer Application Form_6-27-13.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies	FR Citation: 51 FR 42484

Number of Respondents: 400	Number of Respondents for Small Entity: 400

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Pilot Employer Application Form	Attachment I-1_Pilot Employer Application Form_6-25-13.doc	07/25/2013

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