Att H_Employer Follow-up Survey

CDC Work@Health Advance Program: Evaluation of Train-the-Trainer and Advanced Technical Assistance Program

Documents and Forms

Document Name Document Type
Att H_Employer Follow-Up Survey_4-20-15.docx Other-WORD Screenshots

Information Collection (IC) Details

IC Title:	Att H_Employer Follow-up Survey	Agency IC Tracking Number:	15OO

Is this a Common Form? No		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
Other-WORD Screenshots			Att H_Employer Follow-Up Survey_4-20-15.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 60

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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