Information Collection

CDC Worksite Health Scorecard Pilot Evaluation

IC 228461 under ICR 201709-0920-008 · OMB 0920-1014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1014 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1014 CDC Worksite Health Scorecard Pilot Evaluation	Form and Instruction
0920-1014 Attachment C-4 CDC Worksite Scorecard Pilot Eval Screens Attachment C-4 CDC Worksite Scorecard Pilot Eval Screenshots_4.24.2017.pdf	Form and Instruction

IC Title:

CDC Worksite Health Scorecard Pilot Evaluation

Agency IC Tracking Number:

14BE

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-1014	Attachment C-4 CDC Worksite Scorecard Pilot Eval Screenshots_4.24.2017	Attachment C-4 CDC Worksite Scorecard Pilot Eval Screenshots_4.24.2017.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 0920-0136, Epidemiologic Studies and Surveillance of Disease Problems.

FR Citation: 57 FR 62812

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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)	17	17
Annual IC Cost Burden (Dollars)	638	638

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.