Information Collection

Member Satisfaction Survey

IC 251017 under ICR 202502-0920-001 · OMB 0920-0891.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0891 Member Satisfaction Survey	Form and Instruction
Form 0920-0891 Member Satisfaction Survey 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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-0891			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 %

table that charts list of burden
	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
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

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.

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