Information Collection

Member Satisfaction Survey

IC 251017 under ICR 202201-0920-002 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0891 Member Satisfaction Survey	Form and Instruction
0920-0891 Member Satisfaction Survey App N Member Satisfaction Survey DRAFT.docx	Form and Instruction
0920-0891 Member Satisfaction Survey App N Member Satisfaction Survey DRAFT.docx	Form and Instruction

IC Title:

Member Satisfaction Survey

Agency IC Tracking Number:

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	0920-0891	Member Satisfaction Survey	App N Member Satisfaction Survey DRAFT.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-20-0147 Occupational Health Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records

FR Citation: 76 FR 34706

Number of Respondents: 6,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	6,600	6,600
Annual IC Time Burden (Hours)	3,300	3,300
Annual IC Cost Burden (Dollars)	0	0

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.