Hospital Leader - Follow-Up Survey

[NIOSH] Evaluation of Healthcare Worker Mental Health Campaign

Documents and Forms

Document Name Document Type
Hospital Leader - Follow-Up Survey Form and Instruction
Hospital Leader - Follow-Up Survey 5 Hospital leader follow-up survey.docx Form and Instruction
Hospital Leader - Follow-Up Survey 5 Hospital leader follow-up survey.docx Form and Instruction
0920-1415 Hospital Leader - Follow-Up Survey 5 Hospital leader follow-up survey_proposed_clean.docx Form and Instruction
0920-1415 Hospital Leader - Follow-Up Survey 5 Hospital leader follow-up survey_proposed_clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Hospital Leader - Follow-Up Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	NA	Hospital Leader - Follow-Up Survey	5 Hospital leader follow-up survey.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1415	Hospital Leader - Follow-Up Survey	5 Hospital leader follow-up survey_proposed_clean.docx	N/A	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	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	2,000	2,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	1,073	1,073

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.