Information Gathering for Employee Wellness Program Needs (NCI)

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⚠️ Notice: This information collection may be referencing outdated material.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 0925-0642 can be found here:

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Information Gathering for Employee Wellness Program Needs (NCI)	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	Requested	Previously Approved
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

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.