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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.