Information Collection

CDC Worksite Health Scorecard

IC 234914 under ICR 202201-0920-013 · OMB 0920-1014.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1014 CDC Worksite Health Scorecard	Form and Instruction
0920-1014 CDC Worksite Health Scorecard Attachment_C-2_CDC Worksite Health ScoreCard_12-15-21_final.docx	Form and Instruction
0920-1014 CDC Worksite Health Scorecard Attachment_C-2_CDC Worksite Health ScoreCard_12-15-21_final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1014

Is this a Common Form? No

IC Status: Modified

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	0920-1014	CDC Worksite Health Scorecard	Attachment_C-2_CDC Worksite Health ScoreCard_12-15-21_final.docx	na	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 800

Number of Respondents for Small Entity: 600

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	Previously Approved
Annual Number of Responses for this IC	800	0	800
Annual IC Time Burden (Hours)	1,000	400	600
Annual IC Cost Burden (Dollars)	58,280	26,516	31,764

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.