Information Collection

NCEH/ATSDR Wellness Needs Assessment

IC 231065 under ICR 201510-0923-001 · OMB 0923-0047.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0047 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0047 NCEH/ATSDR Wellness Needs Assessment	Form and Instruction
0923-0047 NCEH/ATSDR Wellness Needs Assessment - Screenshot Attachment B2 - NCEH ATSDR Wellness Needs Assessment_screenshots.docx	Form and Instruction
Attachment A1 - Needs Assessment Invitation Email.docx Needs Assessment Invitation Email	IC Document
Attachment A2 - Needs Assessment Reminder Email.docx Needs Assessment Reminder Email	IC Document
RDF_Wellness Needs Assessment_OSSigned.pdf Non-Research Determination	IC Document
0923-0047 NCEH ATSDR Wellness Needs Assessment.pdf GenIC Request	IC Document

IC Title:

NCEH/ATSDR Wellness Needs Assessment

Agency IC Tracking Number:

0923-0047-18ABD

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	0923-0047	NCEH/ATSDR Wellness Needs Assessment - Screenshot	Attachment B2 - NCEH ATSDR Wellness Needs Assessment_screenshots.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Needs Assessment Invitation Email	Attachment A1 - Needs Assessment Invitation Email.docx	04/13/2018
Needs Assessment Reminder Email	Attachment A2 - Needs Assessment Reminder Email.docx	04/13/2018
Non-Research Determination	RDF_Wellness Needs Assessment_OSSigned.pdf	04/13/2018
GenIC Request	0923-0047 NCEH ATSDR Wellness Needs Assessment.pdf	04/13/2018

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