Information Collection

Long Island World Trade Center Health Program Customer Satisfaction Survey

IC 219258 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⚠️ Notice: This information collection may be referencing outdated material.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
Long Island World Trade Center Health Program Customer Satisfaction Survey	Form and Instruction
Patient Satisfaction Survey Long Island Survey.doc	Form and Instruction
Long Island Request form.docx Fast Track GenIC Request	IC Document

IC Title:

Long Island World Trade Center Health Program Customer Satisfaction Survey

Agency IC Tracking Number:

0920-0953-16HC

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 and Instruction	NA	Patient Satisfaction Survey	Long Island Survey.doc	NA	No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,200

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	4,200	4,200
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track GenIC Request	Long Island Request form.docx	12/14/2015

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