CDC Work@Health Employer Application Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1006 can be found here:

Documents and Forms

Document Name Document Type
Att E-1_Work@Health Employer Application Form.doc Other-WORD
Att E-2_ScrShots of Empr Appl Form.docx Att E-2_ScrShots of Empr Appl Form IC Document

Information Collection (IC) Details

IC Title:	CDC Work@Health Employer Application Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 0920-0136, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 600	Number of Respondents for Small Entity: 450

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.