Information Collection

Att D_ Non Respondent Questionnaire

IC 226610 under ICR 201704-0920-010 · OMB 0920-1195.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att D. Non-respondent Questionnaire.docx	Other-WORD & WEB
Att O. Non-Responents Questions (Spanish).docx Att O_Non-Respondent Questionnaire (Spanish)	IC Document

IC Title:

Agency IC Tracking Number:

16AXC

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-WORD & WEB			Att D. Non-respondent Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 63

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	63	63
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att O_Non-Respondent Questionnaire (Spanish)	Att O. Non-Responents Questions (Spanish).docx	04/28/2017

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