Information Collection Request

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH 2)

ICR 201505-0920-003 · OMB 0920-0953 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-0953 Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder units Form and Instruction New Available
Form 0920-0953 Assessment of Personal Protective Equipment Information Database Needs and Capabilities Form New Repair queued
Form 0920-0953 SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey Form and Instruction New Available
Form 0920-0953 Assessment of Personal Protective Equipment Information Database Needs and Capabilities Form New Available
Form 0920-0953 NORA Services Sector Council Questionnaire Form and Instruction New Repair queued
The World Trade Center (WTC) Health Program Customer Satisfaction Survey Form New Available
Form 0920-0953 WTCH Routine Customer Feedback Form and Instruction New Repair queued
Form 0920-17EO NORA Agriculture Forestry and Fishing Council Form and Instruction New Available
NORA Oil and Gas Extraction Council Questionnaire Form and Instruction New Available
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey Form and Instruction New Available
WTC Health Program for Responders at Rutgers University Form New Available
The World Trade Center (WTC) Health Program Call Center Satisfaction Survey Form and Instruction New Repair queued
Form 0920-0953 North Shore LIJ Customer Satisfaction Survey Form and Instruction New Repair queued
Long Island World Trade Center Health Program Customer Satisfaction Survey Form and Instruction New Available
The Nationwide Provider Network Customer Satisfaction Survey Form New Repair queued
Improve Worker Notification Efforts: Survey #2 Form New Available
Improve Worker Notification Efforts: Survey #3 Form New Available
Improve Worker Notification Efforts: Survey #1 Form New Available
North Shore LIJ Customer Satisfaction Survey Form New Available
Generic_Clearance_Submission_Template[1].doc Supplementary Document Uploaded 2012-11-01 Available
NIOSH Part SS-B.docx Supporting Statement B Uploaded 2015-07-09 Available
NIOSH Part SS-A 7 9 15.docx Supporting Statement A Uploaded 2015-07-09 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
231646 Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder units Form and Instruction New
231621 Assessing and Evaluating the Effectiveness of Hazard Recognition and Risk Assessment Interventions Other-WORD New
230826 Assessment of Personal Protective Equipment Information Database Needs and Capabilities Form New
230585 SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey Form and Instruction New
230190 Assessment of Personal Protective Equipment Information Database Needs and Capabilities Form New
229780 NORA Services Sector Council Questionnaire Form and Instruction New
226088 The World Trade Center (WTC) Health Program Customer Satisfaction Survey Form New
226013 WTCH Routine Customer Feedback Form and Instruction New
225018 NIOSH Center for Motor Vehicle Safety Needs Assessment and Audience Analysis Other-WORD New
224575 NORA Agriculture Forestry and Fishing Council Form and Instruction New
223400 NORA Oil and Gas Extraction Council Questionnaire Form and Instruction New
222175 User Feedback Questionnaire for ERHMS Info Manager Other-WORD New
220862 Total Worker Health Capacity Building Letter Other-WORD New
220544 Worker Notification Feedback Survey Other-WORD New
220442 NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Focus Groups Other-Focus Group Guide New
220438 NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Informant Interviews Other-Interview Guide New
219531 World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey Form and Instruction New
219421 WTC Health Program for Responders at Rutgers University Form New
219420 The World Trade Center (WTC) Health Program Call Center Satisfaction Survey Form and Instruction New
219316 North Shore LIJ Customer Satisfaction Survey Form and Instruction New
219258 Long Island World Trade Center Health Program Customer Satisfaction Survey Form and Instruction New
219255 The Nationwide Provider Network Customer Satisfaction Survey Form New
217876 Improve Worker Notification Efforts: Survey #2 Form New
217866 Improve Worker Notification Efforts: Survey #3 Form New
217864 Improve Worker Notification Efforts: Survey #1 Form New
217668 North Shore LIJ Customer Satisfaction Survey Form New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
07/31/2018 36 Months From Approved 12/31/2015
229,800 0 334,500
57,975 0 86,250
0 0 0





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table that charts list of burden
IC Title Form No. Form Name
NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Focus Groups
NIOSH Center for Motor Vehicle Safety Needs Assessment and Audience Analysis
SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey 0920-0953 Member Survey - 2018
The World Trade Center (WTC) Health Program Call Center Satisfaction Survey NA, NA, NA, NA WTCHP Call Center Stisfaction Survey - Program Members ,   WTCHP Call Center Stisfaction Survey - Clinical Centers of Excellence ,   WTCHP Call Center Stisfaction Survey - Health Providers ,   WTCHP Call Center Stisfaction Survey - Pharmacists
User Feedback Questionnaire for ERHMS Info Manager
North Shore LIJ Customer Satisfaction Survey 0920-0953 Queens2018update
Total Worker Health Capacity Building Letter
WTCH Routine Customer Feedback 0920-0953 5-WB2811-Evaluation (3)
Assessment of Personal Protective Equipment Information Database Needs and Capabilities 0920-0953 PPE Survey
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey NA, NA World Trade Center Health Program Member Questionnaire - Telephone Survey ,   World Trade Center Health Program Member Questionnaire - Paper Survey
North Shore LIJ Customer Satisfaction Survey none Customer Satisfaction Survey
Improve Worker Notification Efforts: Survey #3 none Survey #3
Improve Worker Notification Efforts: Survey #2 none Survey 2 Screenshots
WTC Health Program for Responders at Rutgers University none Patient Survey
Assessment of Personal Protective Equipment Information Database Needs and Capabilities 0920-0953 PPE (Personal Protective Equipment) Survey
NORA Agriculture Forestry and Fishing Council 0920-17EO NORA AFF SC questionnaire_Appendix 2
NORA Services Sector Council Questionnaire 0920-0953 National Occupational Research Agenda (NORA)
Assessing and Evaluating the Effectiveness of Hazard Recognition and Risk Assessment Interventions
Improve Worker Notification Efforts: Survey #1 none Survey #1
The Nationwide Provider Network Customer Satisfaction Survey none Survey
NORA Oil and Gas Extraction Council Questionnaire NA NORA Oil and Gas Research Agenda Questionnaire
Long Island World Trade Center Health Program Customer Satisfaction Survey NA Patient Satisfaction Survey
Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder units 0920-0953 Focus Group Discussion Guide Attachment A
NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Informant Interviews
Worker Notification Feedback Survey
The World Trade Center (WTC) Health Program Customer Satisfaction Survey N/A World Trade Center Health Program Member Feedback Questionnaire

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 229,800 334,500 0 -104,700 0 0
Annual Time Burden (Hours) 57,975 86,250 0 -28,275 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


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