Information Collection

World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey

IC 219531 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⚠️ Notice: This information collection may be referencing outdated material.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
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	Form and Instruction
World Trade Center Health Program Member Questionnaire - Attachment A- paper survey.docx	Form and Instruction
World Trade Center Health Program Member Questionnaire - GRCV1TelephoneScriptOMBrevised.docx	Form and Instruction
App-GRCOutreachSurvey.doc GenIC Request	IC Document

IC Title:

World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey

Agency IC Tracking Number:

16JG

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	World Trade Center Health Program Member Questionnaire - Telephone Survey	GRCV1TelephoneScriptOMBrevised.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	World Trade Center Health Program Member Questionnaire - Paper Survey	Attachment A- paper survey.docx	NA	No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,319

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,319	1,319
Annual IC Time Burden (Hours)	180	180
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Request	App-GRCOutreachSurvey.doc	01/08/2016

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