Information Collection

CDC Work Health Organizational Assessment

IC 209578 under ICR 201410-0920-013 · OMB 0920-1006.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att E-5_Work@Health Organizational Assessment.docx	Other-WORD
Att E-6_ScrShots Org Assessment.docx Att E-6_ScrShots Org Assessment	IC Document

IC Title:

CDC Work Health Organizational Assessment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-WORD			Att E-5_Work@Health Organizational Assessment.docx		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: 480

Number of Respondents for Small Entity: 405

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	480	-60	540
Annual IC Time Burden (Hours)	120	-15	135
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att E-6_ScrShots Org Assessment	Att E-6_ScrShots Org Assessment.docx	12/02/2013

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