Information Collection

SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey

IC 230585 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0953 SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey	Form and Instruction
0920-0953 Member Survey - 2018 Member Survey FINAL_SUNY.PDF	Form and Instruction
App- Stony Brook Cust Satisfaction Survey 08MAR2018.doc GenIC Request Template	IC Document

IC Title:

SUNY â Stony Brook CCE WTC Health Program Customer Satisfaction Survey

Agency IC Tracking Number:

0920-0953-18TZ

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	0920-0953	Member Survey - 2018	Member Survey FINAL_SUNY.PDF	NA	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,900

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	1,900	1,900
Annual IC Time Burden (Hours)	158	158
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Request Template	App- Stony Brook Cust Satisfaction Survey 08MAR2018.doc	03/08/2018

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