Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
2019 NIOSH Centers Grantee Meeting Evaluation Survey New 89 16 0 Form none Grantee Meeting Evaluation
Barriers to Care Assessment for WTC Health Program Care at MSSM New 3100 258 0 Form none Barriers to Care Assessment
Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai New 3600 300 0 Form and Instruction none Member Questionnaire - English
Form and Instruction none Member Questionnaire - Polish
Form and Instruction none Member Questionnaire - Spanish
Course Evaluation for Continuing Education Webinars-WTCHP New 1000 83 0 Other-WORD
Other-WORD
Other-WORD
Other-WORD
Other-WORD
Customer Survey for the World Trade Center Health Program Nutrition Department (Stony Brook) New 225 38 0 Form and Instruction n/a World Trade Center Health Program Nutrition Survey
EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey New 2100 175 0 Form and Instruction 0920-0953 Rutgers Patient Satisfaction Survey 2019
Focus Groups to Obtain Input from Construction Workers and Employers New 54 84 0 Other-Spanish Version
Other-Discussion Guide
Other-Employer/Supervisor
Focus Groups-retain Employers New 72 108 0 Form and Instruction 0920-0953 Focus Group Discussion Guide For Employers
Form and Instruction 0920-0953 Focus Group Discussion Guide For Employees
Focus groups to obtain input from construction workers and employers New 54 81 0 Other-Focus group guide
Other-Focus group guide
Other-Focus group guide
Interviews to solicit feedback on COVID-19 Worker Factsheets New 30 15 0 Form and Instruction 0920-20OY Fact sheet testing interview instrument
Member Satisfaction Survey - Stony Brook New 10600 1767 0 Form none Member Satisfaction Survey
Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire New 3800 63 0 Form 0920-0953 Telehealth Services Satisfaction Questionnaire
Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire New 3196 266 0 Other-WORD.doc
Mount Sinai World Trade Center Health Program Clinical Center of Excellence Annual Satisfaction Survey New 23857 5964 0 Form and Instruction 0920-0953 WTC Mt. Sinai Medical Center Annual Survey
NORA CRC Cross-Sector Council Questionnaire New 21 9 0 Form and Instruction 0920-0953 Cross-Sector Survey
NYC Health + Hospitals World Trade Center Environmental Health Center Customer Satisfaction Survey New 5000 417 0 Form 0920-0953 WTC Environmental Health Center Customer Satisfaction Survey
Occupational Data for Health (ODH) Prototype usability testing New 300 75 0 Form 0920-0953 PRE-TEST DEMOGRAPHIC DATA SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH) PROTOTYPE USABILITY TESTING
Form 0920-0953 POST-TEST SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH)
Other-Footer
Other-header
Form and Instruction 0920-0953 Occupational Data for Health (OHD) Phototype Version 3
Form 0920-0953 Employment Status & Retirement dates
Form 0920-0953 Longest Held Occupation
Form 0920-0953 Work History
Occupational Exposure Banding Survey New 200 33 0 Other-WORD
Patient Satisfaction Survey Stony Brook New 2800 94 0 Form 0920-0953 Participation in WTC Health Program at NYUSOM Clinical Center of Excellence
Form 0920-0953 Participation in WTC Health Program at NYUSOM Clinical Center of Excellence (Spanish Version)
Patient Satisfaction Survey Stony Brook New 7000 467 0 Form 0920-0953 Patient Satisfaction Survey
Surveillance Systems Feedback Survey New 858 72 0 Form none Systems Application Feedback
Survey for webinars hosted by NIOSH ORI New 1800 150 0 Other-WORD
Survey to Solicit Feedback on Expanding Research Partnerships: Federal Govt New 188 31 0 Form and Instruction n/a Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: Individuals New 43 7 0 Form and Instruction n/a Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: Private Sector New 223 37 0 Form and Instruction n/a Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: State/Local/Tribal Govt New 266 44 0 Form and Instruction n/a Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on TA on Worker Safety and Health provided as part of COVID response New 1200 240 0 Form none Field TA Survey
Form none Virtual TA Survey
Survey to solicit feedback on Extramural Communication Community of Practice Meetings New 219 37 0 Form and Instruction 0920-0953 Extramural Communication Community of Practice-feedback
TWH Webinar Series New 1750 292 0 Form and Instruction 0920-0953 Webinar Questions
Telehealth Satisfaction at MSSM New 100 8 0 Form and Instruction 0920-0953 TMH QA Questionnaire
Telehealth Satisfaction at MSSM New 20 2 0 Form and Instruction 0920-0953 Telehealth Satisfaction Survey
Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM) New 40 3 0 Form and Instruction n/a Telehealth Services Patient Satisfaction Questionnaire
Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder Units New 48 144 0 Form and Instruction n/a Focus Group Discussion Guide for Online Workplace Violence Prevention Best Practices Courses
Treatment Satisfaction Survey - NYU New 500 17 0 Form none Treatment Satisfaction Survey - English
Form none Treament Satisfaction Survey - Spanish
Winch Entanglement Prevention Technology Interviews New 175 83 0 Form and Instruction 0920-0953 Opening Script and Eligibility Screening Form
Form and Instruction 0920-0953 Representative Question Stems for Interviews
Worker Notification Feedback Survey New 3000 500 0 Form and Instruction 0920-0953 Worker Notification Feedback Survey
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 77528 11980 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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