Information Collection

Healthcare Worker - Follow-Up Survey

IC 261470 under ICR 202308-0920-003 · OMB 0920-1415.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1415 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Healthcare Worker - Follow-Up Survey	Form and Instruction
Healthcare Worker - Follow-Up Survey 4 Healthcare worker follow-up survey.docx	Form and Instruction
Healthcare Worker - Follow-Up Survey 4 Healthcare worker follow-up survey.docx	Form and Instruction

IC Title:

Healthcare Worker - Follow-Up Survey

Agency IC Tracking Number:

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	NA	Healthcare Worker - Follow-Up Survey	4 Healthcare worker follow-up survey.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

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	12,000	12,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	6,435	6,435

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.