Information Collection

Online Survey-All CHWs

IC 223179 under ICR 201604-0990-004 · OMB 0990-0455.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 7_Final OWH WHLI Online Survey.docx	Other-survey
Attachment 7_Final OWH WHLI Online Survey_FINAL.docx	Other-survey

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey			Attachment 7_Final OWH WHLI Online Survey.docx		Yes	Yes	Fillable Fileable
Other-survey			Attachment 7_Final OWH WHLI Online Survey_FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 422

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	422	422
Annual IC Time Burden (Hours)	176	176
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.