Information Collection

The World Trade Center (WTC) Health Program Customer Satisfaction Survey

IC 226088 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⚠️ Notice: This information collection may be referencing outdated material.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
The World Trade Center (WTC) Health Program Customer Satisfaction Survey	Form
World Trade Center Health Program Member Feedback Questi MemberSatisfactionSurvey2017NPN_Final.pdf	Form
Cover Letter membersurvey.Final.docx Cover Letter for the WTC Member Feedback Questionnaire	IC Document
Template App-WTC Member Survey2017.doc GenIC Template for WTC member customer satisfaction survey	IC Document

IC Title:

The World Trade Center (WTC) Health Program Customer Satisfaction Survey

Agency IC Tracking Number:

0920-17WO

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	N/A	World Trade Center Health Program Member Feedback Questionnaire	MemberSatisfactionSurvey2017NPN_Final.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SORN 09-20-0147, Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH

FR Citation: 76 FR 31212

Number of Respondents: 25,000

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	25,000	25,000
Annual IC Time Burden (Hours)	6,250	6,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter for the WTC Member Feedback Questionnaire	Cover Letter membersurvey.Final.docx	03/16/2017
GenIC Template for WTC member customer satisfaction survey	Template App-WTC Member Survey2017.doc	03/16/2017

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