Information Collection

Injury Website Online Survey

IC 213602 under ICR 201405-0920-002 · OMB 0920-1009.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1009 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Injury Website Online Survey	Form
Injury Web Survey Intrument_genIC1009_InjuryWebSite.pdf	Form
Request genIC_1009_Injury WebSite_102314.docx GenIC Request for 0920-1009	IC Document

IC Title:

Injury Website Online Survey

Agency IC Tracking Number:

15CP

IC Status: New

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
Form	None	Injury Web Survey	Intrument_genIC1009_InjuryWebSite.pdf	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	250	250
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Request for 0920-1009	Request genIC_1009_Injury WebSite_102314.docx	10/23/2014

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