Information Collection

Workplace Health in America Survey - core and supplemental

IC 220139 under ICR 201602-0920-009 · OMB 0920-1138.

Documents and Forms

Document Name Document Type
Workplace Health in America Survey - core and supplemental Form and Instruction
Workplace Health in America Survey Attachment C-1_WHA Survey Instrument_2-8-16.docx Form and Instruction
Workplace Health in America -screenshots section 1 Attachment C-2_ScreenShots_Section_1_2-8-16.pdf Form and Instruction
Workplace Health in America - screenshots section 2 Attachment C-2_ScreenShots_Section_2_2-8-16.pdf Form and Instruction
Workplace Health in America - screenshots section 3 Attachment C-2_ScreenShots_Section_3_2-8-16.pdf Form and Instruction
Workplace Health in America - screenshots section 4 Attachment C-2_ScreenShots_Section_4_2-8-16.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Workplace Health in America Survey - core and supplemental	Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Workplace Health in America Survey	Attachment C-1_WHA Survey Instrument_2-8-16.docx	No		Paper Only
Form and Instruction	none	Workplace Health in America -screenshots section 1	Attachment C-2_ScreenShots_Section_1_2-8-16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Workplace Health in America - screenshots section 2	Attachment C-2_ScreenShots_Section_2_2-8-16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Workplace Health in America - screenshots section 3	Attachment C-2_ScreenShots_Section_3_2-8-16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Workplace Health in America - screenshots section 4	Attachment C-2_ScreenShots_Section_4_2-8-16.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,053	Number of Respondents for Small Entity: 3,639

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,053	5,053
Annual IC Time Burden (Hours)	1,053	1,053
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.