Information Collection

North Shore LIJ Customer Satisfaction Survey

IC 217668 under ICR 201505-0920-003 · OMB 0920-0953.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0953 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
North Shore LIJ Customer Satisfaction Survey	Form
Customer Satisfaction Survey North Shore survey.pdf	Form
North Shore fast track.docx Request for Approval	IC Document

IC Title:

North Shore LIJ Customer Satisfaction Survey

Agency IC Tracking Number:

15AZK

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	Customer Satisfaction Survey	North Shore survey.pdf		Yes	No	Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	North Shore fast track.docx	07/28/2015

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