Information Collection

Staff Survey – Preparation Phase

IC 251468 under ICR 202202-0920-001 · OMB 0920-1379.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920- Staff Survey – Preparation Phase	Form and Instruction
0920- Staff Survey -- Preparation Phase Att 3a Staff Survey - Prep Phase.docx	Form and Instruction
Att 4e Staff Survey Inf Con.docx Implementatin Staff Survey Consent Form	IC Document

IC Title:

Staff Survey â Preparation Phase

Agency IC Tracking Number:

0920-21HI

Is this a Common Form? No

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-	Staff Survey -- Preparation Phase	Att 3a Staff Survey - Prep Phase.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Implementatin Staff Survey Consent Form	Att 4e Staff Survey Inf Con.docx	03/09/2022

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