Information Collection

Office of Workers' Compensation Programs Services Stakeholder Surveys

IC 212164 under ICR 201406-1225-002 · OMB 1225-0088.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1225-0088 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
5 question survey script revised.docx	Other-Phone-based survey
Web Survey Screen Capture.docx	Other-Web-based survey introduction
Current Web Survey.pdf	Other-Web-based survey questions
Paper Survey for Longshore (final version).doc	Other-Paper-based survey
Generic_Clearance_Submission_7-21-14.docx Supplemental Justification Supporting Statement for Office of Workers' Compensation Programs Services Stakeholder Survey	IC Document
Introductory Survey Letter (2014-06-20).doc Survey Invitation Letter	IC Document

IC Title:

Office of Workers' Compensation Programs Services Stakeholder Surveys

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Phone-based survey	5 question survey script revised.docx	Yes	Yes	Fillable Fileable
Other-Web-based survey introduction screen	Web Survey Screen Capture.docx	Yes	Yes	Fillable Fileable
Other-Web-based survey questions	Current Web Survey.pdf	Yes	Yes	Fillable Fileable
Other-Paper-based survey	Paper Survey for Longshore (final version).doc	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supplemental Justification Supporting Statement for Office of Workers' Compensation Programs Services Stakeholder Survey	Generic_Clearance_Submission_7-21-14.docx	08/15/2014
Survey Invitation Letter	Introductory Survey Letter (2014-06-20).doc	06/30/2014

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