Information Collection

WTC Health Program for Responders at Rutgers University

IC 219421 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
WTC Health Program for Responders at Rutgers University Form
Patient Survey RutgersSurvey.doc Form
Rutgers Request form.docx Request for Approval IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	WTC Health Program for Responders at Rutgers University	Agency IC Tracking Number:	16HB

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Patient Survey	RutgersSurvey.doc		No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	Rutgers Request form.docx	12/24/2015

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