Information Collection

Pilot Survey

IC 246440 under ICR 202201-0920-018 · OMB 0920-1343.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-21AN Pilot Survey	Form and Instruction
0920-21AN Pilot Survey Attachment 3b.docx	Form and Instruction
0920-21AN Pilot Survey Attachment 3b.docx	Form and Instruction

IC Title:

Pilot Survey

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Unchanged

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	0920-21AN	Pilot Survey	Attachment 3b.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 410

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	Previously Approved
Annual Number of Responses for this IC	410	410
Annual IC Time Burden (Hours)	171	171
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.