Information Collection

Workplace Health in America Survey - core and supplemental

IC 220139 under ICR 201602-0920-009 · OMB 0920-1138.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Workplace Health in America Survey - core and supplemental	Form and Instruction
Workplace Health in America Survey Attachment C-1_WHA Survey Instrument_2-8-16.docx	Form and Instruction
Workplace Health in America -screenshots section 1 Attachment C-2_ScreenShots_Section_1_2-8-16.pdf	Form and Instruction
Workplace Health in America - screenshots section 2 Attachment C-2_ScreenShots_Section_2_2-8-16.pdf	Form and Instruction
Workplace Health in America - screenshots section 3 Attachment C-2_ScreenShots_Section_3_2-8-16.pdf	Form and Instruction
Workplace Health in America - screenshots section 4 Attachment C-2_ScreenShots_Section_4_2-8-16.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Workplace Health in America Survey	Attachment C-1_WHA Survey Instrument_2-8-16.docx	No		Paper Only
Form and Instruction	none	Workplace Health in America -screenshots section 1	Attachment C-2_ScreenShots_Section_1_2-8-16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Workplace Health in America - screenshots section 2	Attachment C-2_ScreenShots_Section_2_2-8-16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Workplace Health in America - screenshots section 3	Attachment C-2_ScreenShots_Section_3_2-8-16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Workplace Health in America - screenshots section 4	Attachment C-2_ScreenShots_Section_4_2-8-16.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,053

Number of Respondents for Small Entity: 3,639

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,053	5,053
Annual IC Time Burden (Hours)	1,053	1,053
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.