Information Collection

Member Satisfaction Survey

IC 251017 under ICR 202402-0920-004 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0891 Member Satisfaction Survey Form and Instruction
Form 0920-0891 Member Satisfaction Survey Form and Instruction
0920-0891 Member Satisfaction Survey App N Member Satisfaction Survey DRAFT.docx Form and Instruction
0920-0891 Member Satisfaction Survey App N Member Satisfaction Survey DRAFT.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Member Satisfaction Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0891	Member Satisfaction Survey	App N Member Satisfaction Survey DRAFT.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records	FR Citation: 76 FR 34706

Number of Respondents: 6,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	6,600	6,600
Annual IC Time Burden (Hours)	3,300	3,300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.