Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0953 can be found here:

Documents and Forms

Document Name Document Type
Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai Form and Instruction
Member Questionnaire - English Barriers to care letter 090718.docx Form and Instruction
Member Questionnaire - Polish Barriers to care letter_POL.docx Form and Instruction
Member Questionnaire - Spanish Barriers to care letter_SPA.docx Form and Instruction
Generic Clearance Submission Template - WTCHP MSSM Barriers to Care091318.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai	Agency IC Tracking Number:	0920-0953-18AZT

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	none	Member Questionnaire - English	Barriers to care letter 090718.docx	No	Paper Only
Form and Instruction	none	Member Questionnaire - Polish	Barriers to care letter_POL.docx	No	Paper Only
Form and Instruction	none	Member Questionnaire - Spanish	Barriers to care letter_SPA.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,600	3,600
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	Generic Clearance Submission Template - WTCHP MSSM Barriers to Care091318.docx	09/13/2018

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