Information Collection

Long Island WTC Health Program Survey

IC 209780 under ICR 201211-0920-003 · OMB 0920-0953.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0953 can be found here:

Documents and Forms

Document Name Document Type
Long Island WTC Health Program Survey Form
Long Island Patient Satisfaction Survey Long Island Survey.doc Form
Long Island app.docx Request for Approval IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Long Island WTC Health Program Survey	Agency IC Tracking Number:

IC Status: New

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	none	Long Island Patient Satisfaction Survey	Long Island Survey.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	4,200	0	0	0	0	0
Annual IC Time Burden (Hours)	280	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	Long Island app.docx	12/18/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.