Information Collection

Staff Survey – Implementation Phase [Months 1, 3, 5]

IC 251470 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 – Implementation Phase [Months 1, 3, 5]	Form and Instruction
0920- Staff Survey -- Implementation Phase (Months 1, 3, 5) Att 3b Staff Survey - Impl Phase 1,3,5.docx	Form and Instruction

IC Title:

Staff Survey â Implementation Phase [Months 1, 3, 5]

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 -- Implementation Phase (Months 1, 3, 5)	Att 3b Staff Survey - Impl Phase 1,3,5.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	24	24
Annual IC Time Burden (Hours)	6	6
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.