Information Collection

Evaluators' Network, Member Survey

IC 253301 under ICR 201902-0920-022 · OMB 0920-1050.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1050 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1050 Network Member Survey Evaluators' Network, Member Survey	Form and Instruction
0920-1050 Network Member Survey 2022 Annual Evaluators' Network Member Survey_5.9.22.pdf	Form and Instruction
0920-1050_Customer_Service_GenIC_Clearance_OSH_Evaluators Network_5.9.22.pdf GenIC Request Template	IC Document

IC Title:

Evaluators' Network, Member Survey

Agency IC Tracking Number:

0920-1050-22FE

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 and Instruction	0920-1050				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 229

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	229	229
Annual IC Time Burden (Hours)	57	57
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Request Template		05/09/2022

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

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