CDC Work@Health Employer Application Form

CDC Work@Health Program: Phase 2 Training and Technical Assistance Evaluation

OMB: 0920-1006

IC ID: 209576

Information Collection (IC) Details

View Information Collection (IC)

CDC Work@Health Employer Application Form
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-WORD Att E-1_Work@Health Employer Application Form.doc Yes Yes Fillable Printable

Health Immunization Management

0920-0136, Epidemiologic Studies and Surveillance of Disease Problems  57 FR 62812

600 450
   
State, Local, and Tribal Governments
 
   100 %

  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 600 0 600 0 0 0
Annual IC Time Burden (Hours) 200 0 200 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Att E-2_ScrShots of Empr Appl Form Att E-2_ScrShots of Empr Appl Form.docx 12/02/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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