Information Collection

Epworth Sleepiness Scale Survey

IC 236927 under ICR 201906-0920-010 · OMB 0920-1278.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1278 can be found here:

Documents and Forms

Document Name Document Type
Form 0920- Epworth Sleepiness Scale Survey Form and Instruction
Appendix G_Email Msg wLinks to Study Survey & Tng.docx Instruction
0920- Appx C4_Epworth Sleepiness Scale Appendix C1-7_Survey and Diary_(WORD).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Epworth Sleepiness Scale Survey	Agency IC Tracking Number:	0920-17BBV

Is this a Common Form? No		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 and Instruction	0920-	Appx C4_Epworth Sleepiness Scale	Appendix C1-7_Survey and Diary_(WORD).docx		Yes	Yes	Fillable Fileable
Instruction			Appendix G_Email Msg wLinks to Study Survey & Tng.docx		Yes	No	Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	2	2
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.