Information Collection

Information Gathering for Employee Wellness Program Needs (NCI)

IC 235381 under ICR 201702-0925-001 · OMB 0925-0642.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0642 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Information Gathering for Employee Wellness Program Needs (NCI)	Form
1 Wellness Survey Questionns Wellness Survey Questions.pdf	Form
Fast Track Request Template-0925-0642 - OHS Survey (1).docx Fast Track Wellness Survey	IC Document
Survey participation email 2019.docx survey email participation	IC Document

IC Title:

Information Gathering for Employee Wellness Program Needs (NCI)

Agency IC Tracking Number:

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	1	Wellness Survey Questionns	Wellness Survey Questions.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	3,000	3,000
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Wellness Survey	Fast Track Request Template-0925-0642 - OHS Survey (1).docx	03/18/2019
survey email participation	Survey participation email 2019.docx	03/18/2019

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